WINTER 2015 TRENDS IN PROTON THERAPY CENTER DESIGN

VOa DESIGN TRENDS IN PROTON THERAPY CENTER DESIGN QUARTERLY WINTER 2015 SCALABILITY THINKING BIG, BUILDING SMALL TREATMENT EVOLVING TREATMENT, ADAPTING DESIGN HEAVY ION CARBON, THE NEXT WAVE? DESIGN BUILDING SMART INTEGRATION EMBRACING AN INTEGRATED MODEL IPD DELIVERING PROTON VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 1 ]

Hampton University Proton Therapy Center VOA DESIGN QUARTERLY WINTER 2015 TRENDS IN PROTON THERAPY DESIGN SCALABILITY THINKING BIG, BUILDING SMALL, PAGE 3 TREATMENT EVOLVING TREATMENT, ADAPTING DESIGN, PAGE 6 CARBON ION CARBON, THE NEXT WAVE?, PAGE 10 DESIGN BUILDING SMART, PAGE 12 IPD DELIVERING PROTON, PAGE 15 INTEGRATION EMBRACING AN INTEGRATED MODEL, PAGE 18 VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 2 ]

TREND SCALABILITY THINKING BIG, BUILDING SMALL Treatment room, Georgia Proton Therapy Center By John Jessen, AIA, NCARB, IIDA When it comes to proton therapy centers, size, complexity and cost have been consistent barriers to entry. The slow but steady proliferation of proton therapy centers in the U.S. has been limited by their girth and expense, which has been dictated in part by the size and space requirements for the bulky proton technology itself; the cyclotron and the gantry primarily. For years we ve known that for proton beam therapy centers to grow worldwide, they would need to be offered in a smaller, cheaper and faster form. TECHNOLOGICAL ADVANCES ARE MAKING PROTON THERAPY CENTERS MORE SCALABLE THAN EVER. VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 3 ]

TREND SCALABILITY INCREDIBLE SHRINKING TECH Recent technological advances make proton therapy centers more scalable than ever. Advances in superconducting magnet technology have decreased the physical size of proton technology. Manufacturers have reduced the circumference of their particle beam accelerators (cyclotrons) as well as the size of the gantries. Advances in power supply technologies suggest power supply rooms can be smaller, too. We see manufacturers starting to develop more compact gantries, which is usually the largest physical piece of proton operating system. Additionally, manufacturers are using superconducting type magnets and moving towards developing more compact equipment components, such as power supply and control cabinets, to further reduce their overall footprint requirement. The equipment technology continues to evolve to the benefit of the end user. The manufacturers are really moving in the right direction in terms of shrinking their physical requirements and energy use. The result is lower building and system operational costs, says Michael Fahey, Managing Principal of Bard, Rao + Athanas Consulting Engineers, PC who regularly consults with VOA on proton therapy centers. Several manufacturers have shrunk the major components and now offer compact proton beam accelerator systems. Mevion S250, IBA Proteus One, Varian ProBeam Compact Single-Room Proton Therapy System, ProNova SC360 and Hitachi PROBEAT-RT are among them. In our view, competition among manufacturers will continue the trend toward more compact technology. PRACTICAL SOLUTIONS VOA/BR+A s experience in designing proton centers has led us to a certain level of comfort with the design considerations that promote further scalability of centers. We ve found, for example, that the size requirements for the technology in the building can be reduced significantly. A continuing dialogue with the proton beam system manufacturer s technical engineering team has yielded significant results. In terms of building size, we have been working with the manufacturers to help them better understand the opportunities they have when applying the building and safety codes that are appropriate to their technology. We re working with them to help them understand where they can further compress their spaces, says Fahey. They re mostly international manufacturers and when they come to the States they are On site coordination at Georgia Proton Center construction VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 4 ]

not as familiar with our codes. For example, defining allowable working clearances required around the equipment. When we educate them on where they can actually further compress areas, as allowed by codes, without compromising the function or serviceability to the equipment, they understand it and adapt accordingly. They recognize the value of what we bring to the table as design professionals. It s not a coincidence that they come to us to redesign, not their equipment, but how it s configured. Manufacturers have been willing to reduce the size of their maintenance and technical areas. Where large overhead cranes may have been required in the past, we now have other design options for accessing maintenance and servicing. Informed by our practical experience New York Proton Therapy Center relative to the actual use of proton beam facilities, VOA is pushing the logic of manufacturer s requirements. Operationally, we ve found that power and cooling requirements are often theoretical figures and higher than what is actually needed. We can reduce these requirements based on our experience with facilities in operation. SINGLE ROOM OPTION For many interested institutions, price and complexity have been barriers to joining the world of proton therapy. Enter the compact single-room solution. Smaller, more affordable, easier to install, simpler to operate and ultimately more realistic to finance, these one-room facilities are poised to increase accessibility to cancer patients around the world. Manufacturers have optimized their systems and can now offer what used to be extensive equipment spread over four or five rooms in just a single room. That type of scale provides flexibility for hospitals to incorporate the technology and evaluate its benefits. It makes proton possible for adoption by small or remote hospitals. The business plan for larger, fiveroom centers will continue to require a hearty number of referrals and high rate of patient throughput to produce a return on investment. Scalability offers more potential options in terms of financial feasibility. I predict we will see growth in these one-room facilities, some of which will be integrated with academic medical settings or cancer centers. Smaller, cheaper, faster is closer than ever. r VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 5 ]

TREND EVOLVING TREATMENT Georgia Proton Therapy Center AN EVOLVING TREATMENT, ADAPTING DESIGN TECHNOLOGICAL INNOVATIONS AND PRACTICAL EXPERIENCE ARE CHANGING THE WAY PROTON THERAPY IS PRACTICED. VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 6 ]

TREND EVOLVING TREATMENT Georgia Proton Therapy Center By Paula Williams, AIA With more than a dozen proton therapy centers in operation in the U.S., the proton community is discovering more applications and techniques for their use. Likewise, new technologies are coming online that make the treatment more effective. This evolution in practice is effecting how we design proton therapy centers. EXPERIENCE As experience accrues in the proton beam community, a better understanding of the application and use of proton therapy has emerged. Clinicians understand when it s appropriate to use proton treatment versus traditional radiation oncology. Instead of an either/or approach, doctors have found that they can mix or combine treatments to achieve more desirable results. With experience, the treatment team is better able to define the appropriate dosage to target the tumors. And proton s advantage for treating pediatric patients, or patients with tumors in more sensitive areas, continues to be realized. PENCIL BEAM The new gold standard in proton beam therapy treatment uses pencil beam scanning. Pencil beam is an advance over current passive scattering proton therapy methods as its beam conforms more closely to the tumor and spares even more surrounding healthy tissue from harm. VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 7 ]

TREND EVOLVING TREATMENT The Proton Therapy Center at Knoxville, TN Pencil beam technology does not require special fittings (customized for each patient s unique tumor characteristics) at the end of the nozzle that delivers the radiation. Over the course of the treatment they require recasting to match the shape of the shrinking tumor. Without the need to house these devices in facilities with pencil beam technology, milling machines are eliminated and storage requirements in the facility are decreased. IN-ROOM IMAGING Another new standard is emerging with on board or in-room imaging. In-room imaging helps ensure that proton therapy s greatest benefits are realized. With imaging technology in the treatment room, proper patient alignment is easier to obtain. Cone beam CTs allow for a greater level of accuracy in proton therapy. With the capability in the room, doctors feel assured that they are hitting the tumor where they are expecting to hit it. With CT scanning capability in the treatment room, clinicians can do real-time, just-in-time imaging to confirm. Not only is this more effective, it increases patient throughput, requires fewer staff and less set-up time. Better monitoring means more imaging equipment, either adjacent to or in the treatment room, thus increasing size requirements. Clients must weigh the benefits of introducing an in-room CT scanner against the necessity of a larger concrete bunker for the treatment room. Post range verification imaging also has many benefits to a proton treatment program. It uses PET CT imaging of the patient s slight VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 8 ]

New York Proton Therapy Center radioactivity post-treatment to see how successfully a tumor has been hit. However, because the window of time after treatment when this can be accomplished is narrow, the PET CT equipment must be located close to the treatment rooms. MORE COMPLEX CASES Previously, American proton treatment centers were envisioned and most closely associated with the treatment of prostate cancer. Prostate cancer has been the most common condition for which a Medicare beneficiary receives proton beam therapy. Prostate cancer treatment, however, usually involves adult patients that are otherwise healthy and mobile. Proton treatment is quick and convenient for those patients. Now, generally speaking, more types of cancers, more complex cases and more tumor types are being treated with proton therapy than ever before. Proton therapy has been proven beneficial for tumors surrounded by sensitive structures such as the eye, brain, and spinal cord, where the potential for radiation damage is very high. A 2012 study published in the journal Radiotherapy and Oncology, found proton beam therapy to be superior to traditional photon therapy for some childhood cancers of the central nervous system as well as cancers of the eye and tumors at the base of the skull. Pediatric cancer, head and neck tumors are among these complex disease states that proton is treating today. Pediatrics requires us to adjust our design as it introduces the extra complexity of anesthetizing young patients. Pediatrics has a different set of space requirements. Kids come in with their families, so there is the need for more waiting space, larger exam rooms, more preparation rooms to prepare the patient as well as recovery suites. Sometimes separate induction rooms are required to keep the treatment room available for treatment rather than preparation. Treating adult patients with complex cases introduces another type of design challenge. These adults are likely to be less mobile, sicker and could be dealing with the effects of chemotherapy or other forms of radiation being delivered in parallel with proton treatment. New proton centers treating these complex cases may find the need for larger nurse stations, as well as sick bays or recovery rooms, rather than just changing and gowned waiting space for the therapist to retrieve the patient. Treating more complex cancers, including pediatric cases, raises the bar for the clinical requirements for proton centers. Increasingly, these centers will need to measure up to hospitals in their healthcare standards and design features. r VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 9 ]

TREND CARBON ION LESSONS FROM PROTON THERAPY CENTER DESIGN WILL COME IN HANDY WHEN THIS PROMISING PARTICLE BEAM TECHNOLOGY BECOMES MORE WIDELY AVAILABLE. CARBON, THE NEXT WAVE? By John Jessen, AIA, NCARB, IIDA One s vision of future of the proton beam therapy industry may depend on perspective and how far ahead one looks. One portion of the industry is looking towards smaller proton centers, even single room solutions and highly cost effective projects. Others are looking beyond protons (hydrogen ions) to see what s next in noninvasive radiotherapy, several years down the road. And that s carbon. Carbon ion beam therapy uses a heavier particle than proton, which has many benefits for the clinician and patient. Carbon ion can reach deeper tissue. Carbon beams release 100% of their radiation energy to the treatment site, rather than proton s 99%, so there s very little damage to healthy tissue. Carbon can carry more radiation to tumor sites and produce 2-3 times higher biological effect compared to X/gamma-rays, which means less patient visits for treatment. A patient s treatment cycle can be shortened by weeks with carbon. Japan, where the profusion of bone cancer cases and demographics make it an attractive treatment option, has pioneered the use of carbon ion therapy. HIMAC, the Heavy Ion Medical Accelerator in Chiba, Japan, began the first full clinical trials with carbon-ion therapy in 1994. Germany is a distant second with the Heidelberg Ion-Beam Therapy (HIT) Center. The conventional view up until recently has been that a carbon ion requires even bulkier, more expensive facilities than proton therapy; more energy and VOA DESIGN QUARTERLY EDUCATION [ 10 ]

TREND CARBON ION Radiation treatment in the Heidelberg Ion-Beam Therapy Center HIT, Photo: Heidelberg University Hospital a robust electrical supply, more cooling from larger chiller pants and bigger magnets in the accelerator to drive the heavier particle. This results in a larger footprint and intimidating expense. But we can take the lessons we ve learned in shrinking the footprint for proton therapy centers from a building efficiency standpoint and apply them to a new developing market for carbon. Incorporating these lessons will make it more likely for carbon to come to market competitively. Working in carbon s favor is the technological evolution of superconducting magnets and power supply devices. Larger magnets are required to push carbon ions, but with superconducting magnets, these are getting smaller all the time. Advances in power supply device technology have helped reduce carbon facility energy demands from 5MW down to just over 2MW. And enthusiasts for carbon say its physical footprint is now only slightly larger (10%) than proton. The smaller footprint Japanese Gunma facility, which opened in 2012, is the prototype for additional, more compact carbon-ion accelerators planned for that country. Carbon still has challenges to overcome beyond equipment and building size and expense. There s no FDA approved system in the United States. And while proton therapy is now covered by Medicare and most health insurance companies in the U.S., carbon ion therapy is considered experimental at present. In Germany and Japan health care providers cover carbon ion therapy. But considering the treatment s great potential and growing interest in the States, these hurdles are unlikely to be permanent. While carbon therapy centers have been talked about in the U.S., they have yet to be built here. But now feasibility studies abound and it s not a question of if we will see a carbon center in the States, but rather when. r VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 11 ]

TREND BUILDING SMART Georgia Proton Therapy Center BUILDING SMART IS ENHANCING PATIENT EXPERIENCE, THROUGHPUT AND COST SAVINGS IN TOMORROW S PROTON THERAPY CENTERS. VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 12 ]

By Paula Williams, AIA By now through our experience in proton therapy center design, we ve accumulated a large knowledge base regarding the particularities of these complex facilities. We know what works and where to look for opportunities to optimize the prevailing model. How is smart design making better proton therapy centers? Here are a few examples: ENHANCING PATIENT EXPERIENCE Increasingly, our designs for proton therapy centers consider the patient experience, whether in the treatment room or outside of it, very carefully. Perhaps most surprising is our approach to the treatment room, where one might assume that radiation would limit available design options. In our earlier projects this space tended to be more utilitarian and functional. But increasingly we find that thoughtful design can make these spaces both comfortable and functional. We ve learned that we can treat these patient treatment rooms as a hospitality environment. Making the patient feel comfortable during radiation therapy is no small achievement. Now, the sky s the limit. Our objective is to create rooms that are as comfortable as any other patient treatment area. We work closely with vendors to ensure their devices line up with our design objectives in these spaces. In the latest facilities, vendors are also showing an amped up brand aesthetic that further enhances the comfortable feel of these spaces. These buildings sound very technical, but when you look closely you can see that there s an opportunity to create beautiful spaces. They represent as much a design opportunity as any other building type. The natural tendency of many, including design professionals, is to assume that these are just concrete bunkers. Really, these are cancer treatment centers with ample design opportunities for both interiors and exteriors. Hampton University Proton Therapy Center VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 13 ]

TREND BUILDING SMART Treatment vestibule at Provision Proton, Knoxville, TN Treatment vestibule, doors closed, at Provision Proton, Knoxville, TN We know how to make proton beam therapy centers functional and safe, bring them in on time and at cost, but we want to make these look great, too. DIRECT ENTRY Radiation shielding for proton therapy centers has typically relied on a maze for entry and exit of the treatment room that prevents particles from escaping. The downside of the maze is that it adds footprint to the concrete bunker and requires patients to navigate it going either way. As a design alternative, VOA has employed shielded, direct-entry sliding doors. This eliminates the maze and a portion of the concrete volume, reducing the footprint of the bunker. Direct entry, in which a patient walks straight into a treatment room rather than following a maze down a long, low-ceilinged corridor, is a more positive, friendly experience. REDUCED SHIELDING We ve found that by analyzing proton center use against specified wall thicknesses we can sensibly reduce shielding in areas where it isn t required to contain radiation. This results in less bulk, a reduced footprint for the bunker and ultimately cost savings. We have found that using steel plate or high density concrete at the end of the proton beam can also reduce bunker size. While it s unlikely that any material will replace concrete in proton center design to encase proton therapy equipment, we are still finding ways to optimize and refine the way it s used. FLEXIBILITY On the clinical side, we re increasingly providing flexible use of space in the layout and program of proton therapy centers. We ve learned to allow for more flexibility for pre-positioning in the room, pre-positioning outside the room and we design more multipurpose rooms rather than those dedicated to a single function. This may not reduce the size of the space, but it makes the spaces more flexible and tends to reduce throughput time. In the previous model, the changing rooms and gowned waiting occurred in a suite attached to a treatment room. Now, both changing and gowned waiting can be associated with four treatment rooms. Centers with a shared pretreatment area, can stage their patients more efficiently and keep more treatment rooms occupied. HIGH RADIATION ZONES While the patient experience can be a primary driver for design in the patient treatment area, design must also consider peak radiation zones in these spaces. As one example, our team researched and substituted LED lighting when we observed that lamps with filaments burned out quickly in these zones. We also work with manufacturers on their technical documents to relocate conduits to lower radiation zones whenever possible. In increasingly scalable proton centers, patient room design is likely to continuing evolving as more compact technology and in-room scanning comes online. r VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 14 ]

TREND: IPD THE COLLABORATIVE PROCESS IN IPD HELPS CONTROL COSTS AND SCHEDULE WHILE ALLOWING US TO FOCUS ON PATIENT EXPERIENCE. DELIVERING PROTON By Franck Le Bousse, DPLG Broadly speaking, the healthcare industry has already embraced integrated project delivery. Soon, it will be standard for healthcare projects to be delivered via IPD. But proton therapy centers are a unique animal. They are, undoubtedly, more complicated to design and build than a typical healthcare facility. Designing a proton center typically requires tasks such as coordinating the placement of 60 miles of conduit, 130,000 lbs of sheet metal with rebar and baseplates in massive concrete walls, all of it documented, coordinated and built over 10,000 file transfers between the design team and the general contractor. All this, not to mention incorporating unique power and water hungry technology found in only a dozen facilities in North America. BIM model, Georgia Proton Therapy Center VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 15 ]

TREND: IPD In general, IPD has many advantages for proton center design. The integrated project delivery method maximizes the use of the latest cloud-based technology allowing the collective talent of the owner, architects, construction managers, subcontractors and equipment vendor to flourish in a collaborative, real-time effort. The VOA/ BR+A team has made efficient use of IPD in delivering proton therapy projects in a design-assist format. BR+A s Managing Principal Michael Fahey says, I tell my staff, if you can deliver a proton center using design-assist IPD format, you can deliver anything. There isn t a harder thing to coordinate than the mass concrete in my opinion. The challenges inherent in proton centers don t end there. Physicists have their requirements, manufacturers prefer certain bending radiuses for the cabling of their devices, and so on. Not only do industry standards apply, but this facility type has an additional layer of complexity factored in to make sure the design will satisfy all the stakeholders. TURN-KEY AND DEVELOPER-LED We are beginning to see both vendors and developers in the industry offer separate turn-key proton center solutions in which they offer an expedited process. In both cases, this process relies on assembling the most qualified team in their proton center package, and an experienced team is more likely to use IPD to its fullest extent. VOA/ BR+A are at the forefront of this approach. DESIGN BUILD Design assist can be used on a conventional designbid-build project. In design assist, we collaborate with engineers and consultants who are proficient in proton technology. VOA has created a team (MEP engineers, structural engineers, shielding consultants) with the knowledge and experience to navigate the IPD process on a proton center. Ideally, this project team also includes a contractor and subcontractors who are proficient in proton design or can be educated on its particularities early in the process. PATIENT EXPERIENCE With the right partner in place, the design team can focus on the details of the patient experience. Using virtual modeling and coordination during the design and construction phases, the team can pilot the design toward creating a comfortable and welcoming experience for its future patients. BENEFITS OF DESIGN-ASSIST When we get the contractors involved during the design BIM model, Georgia Proton Therapy Center VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 16 ]

TREND: IPD Conduits ready to be embedded in the concrete of the Georgia Proton Treatment Center Construction, Georgia Proton Therapy Center phase, we make it mandatory that the contractor demonstrate the effective use of Revit on past projects. The contractor must demonstrate an ability to contribute to a unique 3D model without impeding the collaborative work of the architects and engineers. The complexity of this project type is very demanding on contractors, and general contractors have been slower to embrace this new technology. Once the collaborative partnership is underway, we ll set up a unique Revit model on our server and allocate full access to the model but control the amount of editing allowed for each of the partners and consultants involved in the project. We give them real-time secured access through the cloud. We then define roles and responsibilities on how to work together in that one model. That helps avoid duplicate efforts. When we get to the end of the CD phase, we ve controlled the schedule and we ve controlled the cost. Sometimes we ve reduce the cost. We have a fully coordinated set of documents that have been endorsed by the contractor who has been involved in the process. There is no additional two or three month coordination process between contractors in the field because they did that in partnership with us during the design phase. We have found that this has trimmed at least two months off the front end of the construction schedule. As owners are aware, the faster you get to patient treatment, the faster you begin paying off your investment. r EFFICIENCY In design assist, we transition to working at the shop drawing level early on and quickly bring in MEP elements (conduits, ductwork, etc.) which would only exist on paper in a typical design-bid-build approach. This allows selected subcontractors an opportunity to give their comments and input even on a basic layout. In return, that information gets put back into the construction documents so that by the time CDs are released, that coordination is already done based upon the preferred methods of construction selected by the subcontractors. The biggest benefit is that this method allows subcontractors to go into fabrication sooner. VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 17 ]

TREND INTEGRATED CENTERS EMBRACING AN INTEGRATED MODEL HOSPITALS AND CANCER CENTERS ADD PROTON THERAPY TO THEIR MIX By Franck Le Bousse, DPLG In an effort to offer comprehensive oncology services, a growing number of hospitals are integrating proton centers with traditional cancer treatment facilities. Integrated facilities are outfit with proton therapy equipment as well as traditional photon therapy and other sophisticated radiotherapy devices used in the treatment of cancer. They play host to a multidisciplinary team of doctors, physicists, and dosimetrists who work together to coordinate both conventional radiation and proton therapy treatments. Large hospitals are moving toward an integrated model because it creates new efficiencies, allowing medical centers to offer the entire continuum of cancer treatment options and to apply patient services across various types of care. Baptist Heath Cancer Institute, scheduled to open in 2016, will be among the first cancer centers to provide a fully integrated radiation oncology department. It will offer proton therapy in addition to standard radiation, tomotherapy and gamma knife stereotactic radiosurgery. The new facility will offer a spectrum of integrative medicine services and programs, includ- SAH Global Oman Proton and Imaging Center Site plan, SAH Global Oman Proton and Imaging Center VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 18 ]

TREND: INTEGRATED CENTERS SAH Global Oman Proton and Imaging Center ing infusion chemotherapy, bone marrow transplants and diagnostic imaging. The success of such complex integrated oncology projects depends on careful coordination and thoughtful design. By assembling physicians, nurses, social workers, physical therapists, nutritionists, acupuncturists and counselors under one roof, Baptist Heath South Florida addresses the range of physical and emotional needs associated with all radiation therapies, as well as medical oncology. Even new stand-alone proton centers are considering a mix of proton treatment rooms and traditional LINAC vaults. Beyond enhancing the patient experience, integrated proton centers can make sense from a business perspective. Doctors working across modalities of treatment can benefit from a consolidated administration and centralized clinic for consultations and follow-ups with patients. Typically, proton therapy center construction and vendor equipment installation is a lengthy process. By offering both modalities, centers can open in phases and begin treating patients through conventional channels while their proton facilities come on line. VOA s proposed new design for the SAH Global Oman Proton and Imaging Center features 2 proton treatment rooms and 2 LINAC treatment rooms, allowing for shared nursing, imaging, clinical and administrative services, therefore minimizing duplication of those functions. Another related and emerging trend is the design and construction of a proton therapy center adjacent to an existing radiation oncology department. This approach is not without its challenges. The need for specialized infrastructure makes integration with existing hospital architecture difficult. Proton therapy centers have unique structural requirements due to their large scale and weight a typical cyclotron weighs 220 tons, as much as a 747 airliner, and a magnet weighing over 20,000 lbs. conveys the proton beams to the patient. Beyond the sheer magnitude of the materials involved, the equipment necessitates between 300 and 400 tons of water for cooling and between 1-2 Megawatts of power, enough energy to illuminate 16,000-33,000 60- watt light bulbs simultaneously. Such requirements are beyond the capacity of most hospital campuses. Architects designing integrated proton therapy centers are faced with both practical and aesthetic challenges. Proton treatment facilities typically sit close to the ground with cooling towers and machinery consigned to the roof. This equipment can be unsightly to patients and staff with views from nearby medical towers. Safety is another major concern evaporated coolant from the cyclotron s quench vents and hazardous exhaust from the beamline must be safely discharged so as to avoid release back into the facility or neighboring infrastructure. Despite these challenges, operational hospitals and cancer centers, as well as new stand-alone radiation oncology centers aren t shying away from proton therapy technology. Increasingly, they ll call on experienced design teams to help them add proton treatment rooms to their mix. When it comes to proton therapy, an integrated model is a natural fit. r VOA DESIGN QUARTERLY WINTER 2015 PROTON BEAM THERAPY CENTER DESIGN [ 19 ]

BEIJING, CHINA 79 Jian Guo Road, Suite 403 Office Tower 2, China Central Place Chaoyang District, Beijing, China 100025 BOGOTÁ, COLOMBIA Calle 116 # 7-15 Bogotá, Colombia (Torre Cusezar Of. Avila 401) CHICAGO, ILLINOIS 224 South Michigan Avenue, Suite 1400 Chicago, Illinois 60604 USA HIGHLAND, INDIANA 8145 Kennedy Avenue Highland, Indiana 46322 USA LOS ANGELES, CALIFORNIA 8607 Venice Boulevard Los Angeles, CA 90034 USA NEW YORK, NEW YORK 27 West 20th Street, Suite 800 New York, New York 10011-3726 USA ORLANDO, FLORIDA 4798 New Broad Street, Suite 100 Orlando, Florida 32814 USA VOA Associates Incorporated, founded in 1969, is an international design firm with offices located in Beijing, China; Bogotá, Colombia; Chicago, Illinois; Highland, Indiana; New York City, New York; Orlando, Florida; Washington, D.C.; São Paulo, Brazil and Shanghai, China. We offer comprehensive services for facility programming, master planning, architecture, landscape, sustainability consulting, and interior design. The firm s diversified practice is international in scope and includes: college and university facilities, hotels and hospitality related projects, institutional master plans, financial institutions, corporate headquarters and offices, law firms, housing, healthcare facilities, governmental and transportation-related structures. VOA s ranking as a leading design firm has been affirmed by over 350 local and national awards for design excellence. SÃO PAULO, BRAZIL VOA/LB S/C Ltda. Rua Funchal, 263 Conjunto 64 São Paulo, SP, Brazil 04551-060 SHANGHAI, CHINA 333 Huaihai Road, Shuion Plaza, Suite 2203 Luwan District, Shanghai, China, 200021 WASHINGTON, D.C. 722 12th Street NW, Suite 100 Washington, DC 20005 USA VOA ASSOCIATES INCORPORATED DESIGN QUARTERLY WINTER 2015 Copyright 2015, by VOA Associates Incorporated Book and cover design: VOA Associates Incorporated 071114