Proton Therapy in Singapore

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1 Proton Therapy in Singapore Kam-Weng Fong, MD Radiation Oncologist Chair, Proton Therapy Committee National Cancer Center, Singapore 1 st IAS-CERN Workshop Nanyang Technological University Singapore Mar

2 National Cancer Centre Singapore NCCS Staff Number Medical 117 Nursing 107 Allied Health 133 Research 211 National Referral Centre 55% of all cancers in Singapore 70% public sector cancer patients Administration/Ancilliary 203 Total 771 2

3 Main Hardware Components of Proton Therapy Source: Forbes Website S.Tohoku Layout 3

4 Bragg Peak 4

5 Passive Scattering 5

6 Collimator (Brass) Compensator (Lucite) Active Scanning 6

7 The Cancer Burden 10m new cases in Y2000; 6.2m cancer deaths (12% of all deaths). Estimate by Y % 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 ** 7

8 Radiation Therapy s Long History Rudimentary Equipment, 1896 Coolidge Tube, 1913 Deep Xray, 1930s Telecobaltmach heralded the MV era, c 1948 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 tumouris, conforming to its shape and volume, and avoid exposure to normal tissues 8

9 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 Onco2013 Jan 9

10 Why low dose Regions are Important Ionising Radiation Causes Cancers! 10

11 Radium Girls Female factory workers who painted watch dials with glowin-the-dark paint at the United States Radium factory in Orange, New Jersey around 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 11

12 Deterministic (a) vs Stochastic (b)?? No data for doses <100mSv DRR for Radiation Carcinogenesis Eric J Hall IJROBP 74(2),

13 Excess of 2⁰ Cancers after XRT for Prostate Cancer Fig: Bladder Cancers >5yrs after treatment Surgery XRT XRT associated with higher rates of bladder (1.5X), rectal (1.9X) and lung cancers (1.8X) 2⁰ Cancers Especially Worrisome for Children 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

14 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 14

15 Potentially Avoidable with PT Equal Survival PT vsxrt in Children 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% 2 nd cancer 0% vs6% 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,

16 British NHS Clinical Indications for Proton Therapy Southern Tohoku Proton Therapy Center Japan 16

17 Map:World 10 op 13 new 10 op 10 new, 3 exp 15 op 6 new 1 op 1 exp 1 new Op =operational; New =proposed/building Exp =expansion; Status at end 2010 Data from PTCOG ( and others Map:World No New Centres op 13 new op 10 new, 3 exp Particle Therapy Centres 15 op 6 new op 1 exp Decade 1 new 17

18 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 One Airbus A380 buys 4 Proton Centres 2012 List price for A380 is USD389.9m = S$493.1m; Source: Airbus website 18

19 Cost of the Proton Centre One Gardens by the Bay buys 8 to 9 Proton Centres National effort NCCS PTC 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 19

20 NCCS PTC Currently in planning/design phase Target: treat first patients 2017/ Gantry rooms An experimental beam line depending on interests Thank you 20

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