The document discusses proton therapy for treating oesophageal cancer and its potential benefits over other radiotherapy techniques. It summarizes that proton therapy may significantly reduce side effects from treatment and increase progression-free survival rates compared to IMRT. However, more research is still needed to address issues with dose distribution and motion management. It also stresses the importance of a patient-centered care approach to support patients physically and emotionally throughout treatment to improve quality of life given the poor survival rates for oesophageal cancer.

1. 5NOVEMBER 2016
Proton therapy for the
treatment of oesophageal
cancer: The impact on quality
of life and the need for a
patient centred care pathway.
PROTON THERAPY:
THE PATHWAY TO
PATIENT WELLBEING
SHARON LAVER
C
ancer of the oesophagus is highly malignant and
aggressive, causing 21 deaths a day in the UK1
.
Late diagnosis is common due to the signs and
symptoms being mistaken for those caused by
other non-malignant conditions.The tumour
needs to create an obstruction of approximately 75%
of the oesophageal diameter before symptoms of food
sticking are experienced2
. Consequently, patients often
wait several months before seeking medical help, by
which time 50% will already have unresectable disease
or metastasis2
. Survival rates are low with only 42% of
patients surviving one year post treatment, and only
12-15% surviving 5-10 years1
.
Patients with unresectable disease or those who are
not fit for surgery are treated with either radiotherapy
or chemotherapy or a combination of both1
. Studies
have suggested that combination chemo-radiotherapy
has the greatest impact on tumour shrinkage and cell
apoptosis, and that it subsequently improves survival
rates3
.
However, side effects from this treatment can be very
severe. Patients who are often already undernourished
and experiencing difficulty eating and drinking,
find that the treatment antagonises their symptoms
further. In some cases, stents are required to keep
the oesophagus open to preserve organ function and
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PROTON THERAPY
patients often require specialist support from dieticians.
Some will need to have a percutaneous endoscopic
gastrostomy tube fitted, so nutritional uptake can be
maintained and medicines administered, completely
bypassing the oesophagus.
Therefore, reducing the side effects of treatment for
this patient group could have a significant impact on
their quality of life, which remains an important factor
in view of the poor survival rates.
The aim of this article is to evaluate the role of
proton therapy as a future treatment for oesophageal
cancer patients; in particular the potential impact it
may have on quality of life.The importance of a patient
centred care pathway will also be discussed.
TECHNOLOGICAL DEVELOPMENTS
Recent technological developments within radiotherapy
(RT) have resulted in increased conformity being
achievable. First through the delivery of 3D conformal
radiotherapy (CRT), and further enhanced with the use
of intensity modulated radiotherapy (IMRT).
Chandra et al looked at the differences between
IMRT and 3DCRT toxicity levels when treating areas
within the thoracic region.Their clinically significant
results showed that a seven field IMRT plan reduced
the amount of dose delivered to the lung by 10Gy,
compared to a 3DCRT plan. Evidence has also shown
that patients treated with 3DCRT rather than IMRT have
a higher risk of cardiac-related death4
and that with
current conformal techniques there are still significant
side effects experienced by patients.Therefore recent
and continuing advances, such as the use of proton
therapy may offer promise for further development
in the future with increased scope for sparing more
healthy tissues and organs from radiation induced
toxicity5
.
PROTON THERAPY
Photon and proton beams both work on the principle
of selective cell destruction6
. However, the way the
dose is deposited differs considerably between the two.
Photons are delivered as a total dose, which means
sufficient deposits of photons must be delivered to an
area of tissue to create an ionising effect.This causes
direct and indirect damage to the cancer cells. As
photons lack charge and mass, dose is often delivered
to healthy tissue surrounding the cancerous growth7
.
Compromises are also made around critical organs,
which can result in healthy tissue receiving a higher
dose to ensure that the whole of the tumour is treated
adequately, increasing the toxicity levels and acute side
effects for the patient.
Proton beams can be more accurately directed than
photon beams, with their energy distribution directed
within the target tissue with greater control in a
three-dimensional pattern8
. Protons are energised to
specific velocities and the energy used will determine
how deep the protons penetrate.When protons travel
through the body, they slow down as they interact with
orbiting electrons9
.The complete interaction between
protons and electrons is focused where the proton
reaches its target point (the cancerous growth), to
deliver maximum dose5
.The protons have a steep drop
off rate that further spares healthy tissue, potentially
reducing acute and chronic side effects.
Despite the known advantages of using PT, there are
some drawbacks with the current provision.There are
currently only 58 proton centres operating worldwide
and there are huge cost and space considerations in
housing and implementing the hardware10
.There is also
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3. 7NOVEMBER 2016
PROTON THERAPY
not enough retrospective and prospective data available
to assess disease-related outcomes, long-term and late
effects, prompting large organisations like the Radiation
Therapy Oncology Group (RTOG) and the Children’s
Oncology Group (COG) to include proton therapy in
several clinical trials. A further limitation is the lack of
proton therapy trained therapeutic radiographers11
.With
the imminent use of PT in the UK it is also necessary
to educate students within the current and future
radiotherapy curriculum about delivery techniques and
patient management.With proton therapy machines
now scheduled to arrive in the UK training of current
RT staff and RT students will need to be given urgent
attention, to build staffing levels and support career
progression within this field.
The comparison of proton to IMRT and 3DCRT
treatment plans for treating cancer of the oesophagus
demonstrates that the drop off rate for protons is
very sharp, with a reduced exit dose, making proton
therapy ideal for sparing the surrounding tissues and
organs from increased toxicity12
. Dosimetric studies,
comparing 3DCRT, IMRT and PT for the treatment of
patients with locally advanced oesophageal carcinoma
showed reduced dosimetric parameters in the PT plan,
especially for the heart, lung, kidneys and liver13
. A
further retrospective comparison showed that patients
receiving treatment with RT photons received some
toxicities, whereas the proton group exhibited no
graded toxicities14
. Currently, there is a phase three
trial comparing PT and IMRT with equivalent doses,
considering the progression-free survival rates. Final
data collection is 18 April 2018 after which the results
will follow (NCT01512589)15
.
The dose to surrounding critical structures when
using PT has been shown to be significantly reduced,
yet the deposition of dose to the proximal target is
not highly conformal16
. Recent technological advances
include the use of magnets to steer the beam.This
is referred to as intensity modulated proton therapy
(IMPT)17
. A study selecting patients with distal
oesophageal cancer had two treatment arms: one
arm prescribed 65.8Gy delivered using IMPT and the
other 50.4Gy delivered using IMRT over 28 fractions
using a three field arrangement. Results from a
multi-institutional analysis involving 582 patients at
the Mayo clinic and the University of Maryland showed
greater sparing of the heart, lungs, liver and spinal cord,
reducing nausea (29% vs 50%), fatigue (27% vs 33%),
hematologic toxicity (2% vs 26%) using IMPT18
.These
findings suggest there may be advantages for the use of
IMPT over IMRT for oesophageal cancer patients.
However, there are concerns over the dose
distribution of PT treatments, as they are affected
by varying tissue densities to a greater degree than
photons. Due to this concern, there is hesitancy to
use this technique on structures that have respiratory
movement. Further dosimetric studies have been able
to identify robust beam angles which take into account
respiratory movement.With advancement in 4D CT,
motion robustness using IMPT looks promising for
treating distal oesophageal cancer, which has relatively
small motion19
.
Studies involving PT/IMPT and dose escalation
suggest that increased dose is feasible, especially with
advancing diagnostic techniques alongside the use of
4D CT, fiducial markers and cone beam imaging.Two
further trials are underway in France (CONCORDE,
NCT01348217) and the Netherlands (ART DECO,
NTR3532) to assess the effect of dose escalation on
unresectable oesophageal tumours, while other studies
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4. 8 NOVEMBER 2016
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in China are showing significant progress in local
disease control with escalated dose5
.
Under current treatment, toxicity deposited to the
heart and lungs is of particular concern as photon RT
is already associated with pulmonary complications
and is known to contribute to heart failure20
.
However, to date there are few studies comparing
PT/IMPT with other current treatments being used
throughout the UK (3DCRT/IMRT) in conjunction with
chemotherapy. Until further research is carried out, the
recommendations and present treatment and protocols
will remain the same with the recommendation of
chemo-radiation21
.
PATIENT CARE
In light of these studies and technological advances, PT
could have a promising role in the treatment of some
oesophageal cancers.With the prospect of increased
dose escalation and better beam conformity, there is a
high possibility of improving survival rates, reducing
side effects of treatment and enhancing patients’ quality
of life. Ensuring that the side effects are minimised is
of great importance for these patients, as prognosis
and long term survival is often poor22
. Over 50% of
oesophageal cancer patients present with late stage
disease at diagnosis23
.
One of the most common symptoms of oesophageal
cancer is dysphagia which as well as being painful,
impacts on the performance of the oesophagus and can
prevent patients from achieving adequate nutritional
intake. Consequently, patients often present in poor
physical condition, and are placed on a care pathway
centred on palliative treatment as surgery is no longer a
viable option22
.
During treatment, there can be a series of physical
changes to the patient’s body, due to a lack of appetite,
tiredness and pain. Part of the palliative care team’s role
is to ensure treatment is delivered to retain the function
of the oesophagus24
. Interventions will come from a
managed number of different specialists, including
dieticians, GPs, physiotherapists and specialist nurses
as well as RT staff. Interprofessional working and
shared access to patient notes across a range of teams is
essential for delivering a consistent and optimised care
package for each patient’s particular circumstances.The
creation of a patient centred care (PCC) plan facilitates
the coordination of an effective multi-disciplinary
approach to deal with the specialist treatments and
handovers at different phases of care25
. Monitoring
and management of pain, in particular, are ongoing
processes involving all professionals dealing with the
patient throughout treatment26
.
Receiving a diagnosis of cancer involves significantly
more than just the impending physical treatment of the
disease. It can be very emotional and is likely to cause
considerable upset to the patient and their families/
carers. Patients can experience a sense of fear and
bewilderment, resulting in them feeling completely out
of control and not being able to take in information to
make decisions, able to inform or support themselves27
.
PCC is designed to restore control and confidence to
the patient, by involving them and their carers in the
treatment plan, specifically tailored to each patient, to
deliver the optimal outcome as determined by the patient.
This includes supporting the wider non-clinical needs28
.
The physical changes can often have a profound
impact on how the patients view themselves.
Degradation in oesophageal functionality, overall
physical condition and ability to carry on life as usual,
can affect self-esteem, motivation and emotional
well-being and often results in depression, requiring
further specialist involvement29
.
Evidence suggests that having a holistic needs
assessment, including non-medical, psychosocial
aspects of care can significantly improve patient
outcomes:‘The term psychosocial care includes the

5. 9NOVEMBER 2016
GLOSSARY OF TERMS
RT Radiotherapy
3D CRT 3 Dimensional Conformal Radiotherapy
IMRT Intensity Modulated Radiotherapy
Gy Gray Measurement of radiation unit
PT Proton therapy
RTOG Radiation Therapy Oncology Group
COG Children’s Oncology Group
IMPT Intensity Modulated Proton Therapy
4D CT Four dimensional computed
tomography
GP General practitioners
PCC Person/patient centred care
PROTON THERAPY
psychosocial, social, spiritual, and practical needs of
the patient and carers. Assessing all their needs and
addressing where possible’28
.
A needs assessment can identify any difficulties,
which could potentially cause stress to the patient,
prompting discussions directly with healthcare
professionals or outside organisations. It helps to
develop trust, with the patient feeling they are
being treated as an individual and promotes open
communication and information sharing, which enables
the patient to make informed choices about their care30
.
Not all patients will have the health education to
immediately understand their condition and options
available to them. Open conversations with the patient
and carers, sensitively handled at the right time,
can seek to improve their understanding30
. Patients
may require repeated consultations with a variety of
professionals, to acquire the knowledge necessary
for their involvement in building their care package.
While not all professionals will be involved in every
meeting to discuss patient wishes, shared access to
and a common understanding of that plan, will enable
continuity of treatment across the team30
.
One of the core aims of the PCC plan31
is to maximise
the patients’ quality of life and give them the strength
to carry on doing what they enjoy most, for the longest
amount of time possible. Involvement in defining
the plan, and understanding of the condition and its
progress, enables the patient to better self-manage their
treatment pathway, including pain relief, and often leads
to reports of greater satisfaction with the care received.
In terminal cases, the pathway includes a plan both
for dying, to ensure that patient retains their dignity
and choice to the end; and also for post-death support
for the family30
. Family finances and wellbeing are often
amongst the prime concerns for these patients, and can
require involvement and reassurance from other social
care teams.
Carers are often slower to accept the diagnosis and
prognosis that the patient has managed to accept.
Although the patient determines the level to which
these individuals are involved, with patient consent,
carers ideally form part of the PCC team.While they are
not the focus of the care plan, it is recognised that the
burden of caring for the patient can lead to physical
as well as mental/emotional pressures that themselves
require support31
. Both specialist and social care teams
may also become involved in supporting and caring for
these carers. In the best scenarios, ongoing support for
the carers and relatives can continue after the death of
the patient, to ensure that they can recover emotionally
and in some cases, physically function themselves.
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6. 10 NOVEMBER 2016
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ABOUT THE AUTHOR
By: Sharon Laver, second year student
BSc Radiotherapy & Oncology, Sheffield
Hallam University.
REFERENCES
http://www.sor.org//learning/library-
publications/itp
This article has been prepared following
local guidance relating to the use of
patient data and medical images.
To comment on this article, please write
to editorial@itpmagazine.co.uk
CONCLUSION
There is a building portfolio of evidence that suggests
the use of PT/IMPT as a treatment for oesophageal
cancer, may significantly reduce the acute side effects of
treatment.Trials have also demonstrated the potential
for greater progression free survival, increasing the
demand for further research in this area.
However, issues surrounding the impact of varying
tissue densities on PT dose distribution require more
research, including limiting the impact of respiratory
and organ motion during treatment delivery.
The availability of proton therapy treatment delivery
sites is also a limiting factor in the progression of this
treatment being adopted nationally.
Oesophageal cancer is an aggressive disease within
a complex part of the anatomy. Delivering treatment
that can further the patient’s progression free survival
and improve quality of life is of great importance, as
fewer side effects will contribute to the patient’s overall
wellbeing.With a PCC team approach as described,
patients should be able to retain control over their
care whilst being well supported, thus enhancing their
quality of life.
ACKNOWLEDGEMENT
I would like to thank Keeley Rosbottom, Senior Lecturer
at Sheffield Hallam University, for all her help and
support throughout my studies and in preparing this
article.
HOW TO USE THIS ARTICLE FOR CPD
Description
The article focuses on proton vs photon
therapy for oesophageal cancer patients,
looking at reducing toxicities to healthy
tissues and the prospect of escalating dose.
The article explains how proton therapy
works in comparison to today’s treatments.
Reflect on the article and identify new
pathways to increase and continue your
learning about proton therapy.
Description
Reflection is an important stage of
controlling our continued professional
development. Proton therapy centres are
due to open in 2017.
Due to limited research in proton therapy
at present, it can be assumed that this
will be an active area of development,
requiring us to engage and further our
knowledge in proton therapy.
Holistic needs assessment
Investigate if your department uses a
holistic needs assessment, at what stages of
treatment is it implemented and how can
this improve the patient’s quality of care?
If your department does not use a holistic
needs assessment, what alternatives are
put in place to monitor the holistic care
of oesophageal cancer patients, and are all
their needs met?
Share
Sharing new knowledge with others
is a great way of engaging others and
cementing your own knowledge.
Pass on what you have learned and
encourage others to read the article,
‘improving outcomes for oesophageal
cancer using proton beam therapy’.
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