The Promise of Protons The Economic Club of Florida, Tallahassee 2018 - - PowerPoint PPT Presentation

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The Promise of Protons The Economic Club of Florida, Tallahassee 2018 - - PowerPoint PPT Presentation

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The Economic Club of Florida Tallahassee August 13, 2018 Nancy P Mendenhall, MD The Promise of Protons The Economic Club of Florida, Tallahassee 2018 0813 The Promise of Protons Cancer and radiation therapy The promise of protons

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The Promise of Protons

The Economic Club of Florida Tallahassee August 13, 2018 Nancy P Mendenhall, MD

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons

  • Cancer and radiation therapy
  • The promise of protons
  • UFHPTI: missions and operation
  • The economic impact
  • The future…….
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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons

Cancer and Radiation

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Cancer & Radiation

  • Cancer affects 1 in every 3 Americans
  • Cancer is 2nd most common cause of

death in the US

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Cancer & Radiation

Standard Cancer Therapy

Local

Surgery Radiation

Systemic

Chemotherapy

Hormonal & Targeted therapy

Immunotherapy

  • Cryosurgery, laser, & HIFU are local therapies used in certain settings.
  • Radiation may be delivered with an external source (external beam

therapy), an implanted or intracavitary source (brachytherapy), or an isotope (systemic)

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Cancer & Radiation

  • Radiation used in ~50% of cancer patients
  • Most is External Beam Radiation Therapy

using a radiation source external to patient’s body

  • Most EBRT uses X rays (Photons) aka

“conventional radiation therapy”

Including cancers of the prostate, breast, lung, colorectum, brain, head & neck, female organs, male organs, urinary tract, lymphatic system, and children

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons

The Promise of Protons

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First Principles of Radiation Therapy

Radiation Therapy is a non- specific treatment

  • Damages normal tissue

as well as cancer

  • Damage is dose-related

and volume-related

  • Dose distribution is key

determinant of the patient’s outcome

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0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 5 10 15 20 25 30

Percent Depth Dose Water-Equivalent Depth (g/cm2)

Depth dose comparison of 18 MV X-rays & Protons

Dose Distribution: Depth dose for X rays & Protons

18 MV Photon (X ray) 18 MV Photon (X ray) Proton

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Photons (X rays)

  • X rays leave a track of damage like a bullet
  • The dose decreases with depth of penetration
  • There is a higher dose (red) along the entrance

path than in the target, and more dose along the exit path

  • Protons are particles with mass; they only penetrate

the body according to the energy they are given

  • They can be programmed to stop in the target (tumor)
  • The entrance dose is much less and there is no exit

dose

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WHAT IS THE IMPACT OF RADIATION DOSE TO NORMAL TISSUE?

Modeling Radiation Dosimetry to Predict Cognitive Outcomes in Pediatric Patients with CNS Embryonal Tumors Including Medulloblastoma

Merchant et al, IJROBP - 2006

  • Each Gy increased IQ decline
  • THERE WAS NO DOSE THRESHOLD
  • Merchant. Cancer J 15:298-305.

Merchant et al. J Neurosurg 104: 94-102. Merchant et al. Pediatr Blood Cancer 51: 110-117. Merchant et al. J Clin Oncol 27: 3691-3697.

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Craniopharyngioma: IMRT vs SRT vs PT

Craniopharyngioma-Comparative Dose Distribution IMRT:photons SBRT: photons Protons

CLINICAL DATA: ~850 pediatric brain tumors treated, including >100 craniopharyngiomas, pc Dr. Daniel Indelicato.. Collaboration with St. Jude Research Hospital, NHS, PPCR

Mean Dose cGyE IMRT STR PT % dec with PT body 233 215 63 71% brain 888 810 358 65% LTL 951 1200 370 61% LH 2749 3299 815 61% Target Dose of 54 GyE

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36 Gy/CGE Mean Dose Cardiac IMRT Proton Mean Dose 20 1 Dosimetry: courtesy of Z Li PhD, D Louis CMD. RATIONALE: Increased risk of 2nd malignancy with dose ≥ 4 Gy (Travis et al, 2002, 2003, Tukenova, 2010) Increased risk of cardiac disease with doses ≥1Gy (Mulrooney 2009, Darby 2013).

Craniospinal Axis Irradiation: 3DCRT vs PT Medulloblastoma: Photons & Protons

CLINICAL DATA: Giantsoudi et al, IJROBP 95: 2016: 111 children, 5 y, similar disease control and acute toxicity to historical controls. …anticipating less late effects.

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Impact of Radiation on Ischemic Heart Disease in Breast Cancer Patients

DESPITE A SURVIVAL ADVANTAGE WITH with RADIATION in breast cancer…. The rate of major cardiac events increased by 7.4% for each increase of 1 Gy in the mean RT dose to the heart

Darby S et al. Risk of Ischemic Heart Disease in Women after Radiotherapy for Breast Cancer. New England Journal of Medicine 2013; 368(11):987-98

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Breast Cancer: IMRT and PT

Xu et al Can proton therapy improve the therapeutic ratio in breast cancer patients at risk for nodal disease? Am J Clin Oncol 2013. Bradley et al. Early Clinical Results. 2017.

IMRT 3DPT

Mean heart dose

5 Gy 1Gy

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons

UFHPTI:

The University of Florida Proton Therapy Institute

Mission and Operation

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University of Florida Proton Therapy Institute Mission

With the compelling rationale for protons, UF decided to create a proton facility Missions

  • Provide best patient care possible
  • Conduct research into best indications and

techniques for proton therapy

  • Fiscal stewardship*
  • Education

*Funded by state grants, city loans, bonds, philanthropy

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University of Florida Proton Therapy Institute: Operations

  • 1st proton facility in Southeast US, opened in 2006
  • 501c3, Affiliated with University of Florida
  • Mission of Patient Care and Proton Therapy

Research

  • >255K treatments to >7500 patients, >1500 children
  • ~40 Prospective Clinical Trials and Studies
  • ~98% of patients involved in outcome studies
  • 150 staff including 11 subspecialty MDs, 11 PhD

Physicists, and 12 engineers

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Gainesville: University of Florida and College of Medicine (COM) Jacksonville: second UF COM campus and site of the UF Proton Therapy Institute Population ~ 1.3 m International air and sea ports Excellent interstate highways

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UFHPTI Treatment Floor

Simulation

Proton Area Photon Area

PET-CT Large Bore CT MR

Eye Treatment Room

230 MeV Cyclotron

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Facility 440,000 lbs Cyclotron

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Facility

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Facility 3 Story - 200,000 lbs Gantry

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Facility

Proton Treatment Room and Nozzle

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Clinical Operation

Clinical Mission

Daily >90 patients 14-16 operating hours

  • Prostate
  • Breast
  • Pediatrics
  • Lung
  • Lymphoma
  • Pancreas
  • Head & Neck
  • Sarcoma
  • Bone
  • Eye
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Current Expansion Project Current Expansion Project

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Expansion

Expansion Fun Facts:

  • ~11,000 Sq. Ft. project
  • 172 tons (344K pounds) of steel rebar
  • 210 trucks of high density concrete
  • 8.8 million pounds of concrete
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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Research Operation UFHPTI Research Mission

  • 98% patient participation in in-house IRB

approved Outcomes Tracking Protocol

  • ~40% also in bench mark, optimization,

comparative IRB approved studies

  • ~40 clinical research trials/studies conducted
  • Currently 18 open
  • >130 publications to date in peer reviewed

medical journals dealing with technical issues and clinical outcomes treatment

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Research Operation UFHPTI Research Mission

  • Collaborations with
  • St. Jude
  • Pediatric Proton Cooperative Registry
  • Proton Cooperative Group
  • Mayo Clinic
  • University of Pennsylvania
  • PROSTQA Prostate Study Group
  • Radiation Therapy Oncology Group/NRG
  • Aarhus University Netherlands
  • University of Groningen
  • COMPPARE consortium
  • First UFHPTI/UF federal funded research

grant 2018

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons

UFHPTI:

The Economic Impact of UFHPTI

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Economic Impact

  • Covered by Medicare and most

major insurers

  • The actual proton treatment

takes 1-10 minutes

  • Each treatment visit takes 15-60

minutes

  • Patients receive proton therapy

daily for 6-8 weeks after a 1-2 week planning interval

  • ~900 patients are evaluated for

protons each year

  • ~3000 physical followup visits

annually

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Economic Impact

  • Initial capital investment = $125 million*
  • Current expansion / equipment upgrade

project = $44 million

  • Total employees = 193 FTEs [152 (UFHPTI) +

26(UF) +15(IBA)]

  • Total annual operating budget = ~$46.1

million

*State grants, city loans, bonds, philanthropy

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Economic Impact

  • ~60% of patients

travel >60 miles

  • All US states &

32 countries including:

  • U.K.
  • Canada
  • Australia
  • Norway
  • Peru
  • Saudi Arabia
  • Hong Kong
  • Mainland China
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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Economic Impact

  • Patients typically in JAX for 2-3 months
  • >100 short-term housing options are

currently offered on our web site

  • Estimated average ~$5,500/person spent

by non-local patients for food, housing, transportation and entertainment

  • Estimated non-medical expenditures

>$25 million since 2006

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Research Economics

  • Research Mission is critically important

to patients, institution, society

  • Answers questions of best indications

and techniques for proton therapy

  • UFHPTI is not only a clinical, but also a

research leader in proton therapy

  • UFHPTI Research to date has been

funded by operating revenue, philanthropy, state and regional grants ($2m per year)……

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PCa: IMRT and PT Dose Distribution

Obvious difference in radiation dose distribution between IMRT and Protons in Prostate Cancer: Does it make a difference?

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Observations from UFHPTI published prostate cancer trials/studies & published IMRT results on disease control (PSA)

Mind the Gap!!!

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: Research Economics

  • Results from UFHPT prostate cancer

trials provided the basis for a federally funded national clinical trial, COMPPARE, which will compare

  • utcomes of 3000 men treated for

prostate cancer with IMRT vs Protons

  • 44 institutions, UF leadership, funding

by PCORI ($11.9m over 5 years)

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons

The Future…..

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The Economic Club of Florida, Tallahassee 2018 0813

The Promise of Protons: The Future

  • With the compelling rationale and first

decade of clinical, research, and

  • perational results, we believe the

future is bright

  • More clinical expansion, enhanced

technology, more research to probe the limits of the Promise of Protons ….

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University of Florida Health Proton Therapy Institute

www.floridaproton.org