Proton Therapy in Singapore - Nanyang Technological · PDF file3/26/2013 1 Proton Therapy in...
Transcript of Proton Therapy in Singapore - Nanyang Technological · PDF file3/26/2013 1 Proton Therapy in...
3/26/2013
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Proton Therapy in Singapore
Kam-Weng Fong, MD
Radiation Oncologist
Chair, Proton Therapy Committee
National Cancer Center, Singapore
1st IAS-CERN Workshop
Nanyang Technological University
Singapore
25-27 Mar 2013
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National Cancer Centre Singapore
NCCS
• National Referral Centre
– 55% of all cancers in
Singapore
– 70% public sector cancer
patients
Staff Number
Medical 117
Nursing 107
Allied Health 133
Research 211
Administration/Ancilliary 203
Total 771
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The Cancer Burden
• 10m new cases in Y2000; 6.2m cancer deaths (12% of all deaths). Estimate by Y2020 50% increase in new cases.*
• In developed societies contributes 25% of deaths (Singapore 29.3% or 5023 deaths, Y2008**)
• 50-60% of cancer sufferers benefit from the use of Radiation Therapy
*WHO www.who.int/mediacentre/news/releases/2003/pr27/en/
** www.moh.gov.sg/mohcorp/statistics.aspx?id=5526
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Radiation Therapy’s Long History
Rudimentary
Equipment, 1896Coolidge Tube,
1913
Telecobalt mach
heralded the MV
era, c 1948
Deep Xray, 1930s
Linear Accelerator
Stanford, 1956
Modern Linac
with onboard
imaging
Mantra of Radiation Oncology
• Dose Conformality (tumour)
• Dose Avoidance (normal organs)
• i.e. Put the intended high dose of radiation
where the tumour is, conforming to its shape
and volume, and avoid exposure to normal
tissues
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Conformality of Radiation Delivery
• Allows dose escalation to improve local
control rates
• Reduces exposure to normal tissues reducing
side effects/complications
Timeline of RT Technologies
Source: Nat Rev Clin Onco 2013 Jan
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“Radium Girls”
Female factory
workers who painted
watch dials with glow-
in-the-dark paint at
the United States
Radium factory in
Orange, New Jersey
around 1917. The
women, who had
been told the paint
was harmless,
ingested deadly
amounts of radium by
licking their
paintbrushes to
sharpen them.
Epidemiological Case Sudies
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Deterministic (a) vs Stochastic (b)
??No data for doses
<100mSv
DRR for Radiation Carcinogenesis
Eric J Hall IJROBP 74(2), 209
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Excess of 2⁰ Cancers after XRT for
Prostate Cancer
Fig: Bladder Cancers
>5yrs after treatment
XRT associated with higher rates of bladder (1.5X), rectal (1.9X) and lung cancers (1.8X)
Surgery
XRT
The risk is 7 to 12 times higher with
conventional radiotherapy + IMRT
compared to proton therapy
The risk of developing a second cancer after receiving
craniospinal proton irradiation
Newhauser W e tal
MD Anderson, Washington University
Physics in Medicine and Biology 2009
2⁰ Cancers Especially Worrisome
for Children
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Deterministic Effects in Childhood
A CASE DESCRIPTION
• 40 year old male who was treated with x-ray RT as a young child for
orbital rhabdomyosarcoma in the left eye through lateral opposed
fields following surgery to remove the eye and tumor. The radiation
resulted in growth failure in the mid face, mental retardation and
permanent scarring in the skin demarking the entrance and exit area
of the beams.
• Patient has IQ of a 6 year old, has visual impairment and
communicates poorly.
• Lives with and looked after by an elder sister. Although patient can
feed himself, he needs help with other activities of daily living
Cost of Side-Effects
• Mental Retardation & Visual Impairment: special education
needs, life potential truncated, loss to workforce & economic
contribution
• Hormonal hypofunction: Surveillance & life-long follow-up,
hormonal replacement
• Loss of Independence: Cost to family dedicating a caregiver,
economic loss from caregiver commitment, state steps in
when family caregiver unable to cope or ages
• Poor lifelong health: Increased risk of infections &
degenerative illnesses because of poor self-care
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Potentially Avoidable with PT
PT vs XRT in ChildrenEqual Survival Proton vs Conventional
Decreased Height 20% vs 50%
Facial hypoplasia 60% vs 80%
Dental problems 30% vs 100%
Cognitive functions 10% vs 35%
Visual changes 0% vs 40%
Hearing loss 0% vs 40%
2nd cancer 0% vs 6%
“70% of paediatric cancer patients are ultimately cured.
Techniques to reduce growth / development abnormalities
as well as second malignancies are of great importance.”Yock et al, 2005
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British NHS
Clinical Indications for Proton Therapy
Southern Tohoku Proton Therapy Center
Japan
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15 op
6 new
10 op
10 new, 3
exp
10 op
13 new
1 op
1 exp
Data from PTCOG (http://ptcog.web.psi.ch/) and others
Map:World
1 new
Op =operational; New =proposed/building
Exp =expansion; Status at end 2010
15 op
6 new
10 op
10 new, 3
exp
10 op
13 new
1 op
1 exp
Map:World
1 new
0
5
10
15
20
25
30
1960 1970 1980 1990 2000 2010 2020
No New Centres
Decade
Particle Therapy Centres
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Cost of the Proton Centre
• Equipment cost approx. S$100 million
• Costs mitigated by constructing it as part of
the new National Cancer Centre building
• Exploring strategies to lower cost of financing
• Lifespan of Proton Centre is at least 20 years
• Overall goal: to make proton therapy
affordable to Singaporeans
Cost of the Proton Centre
2012 List price for A380 is USD389.9m = S$493.1m; Source: Airbus website
One Airbus A380 buys 4 Proton Centres
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One Gardens by the Bay buys 8 to 9 Proton Centres
Cost of the Proton Centre
NCCS PTC
• National effort
– Involvement of other clinical partners
• Benefit patients of Singapore & the region
• Contribute to evidence for clinical roles
– Particularly for ‘endemic’ cancers such as
nasopharyngeal and liver cancers
• Provide a platform for technical and scientific
research