Proton Radiation Therapy, a New Weapon Against Cancer

26 Feb 2019 News

The oncologists demand that Spain equip itself with specialized rooms to offer this treatment

In August 2014, the case of four-year-old British boy Ashya King made headlines. The little boy had been diagnosed with medulloblastoma, a type of malignant cranial tumor. He had received surgery and was waiting to be treated with chemotherapy and radiotherapy when his parents decided to remove him irregularly from the hospital in the United Kingdom where he was admitted and travel to Prague for proton treatment.

Like Ashya King, although without the epic that enveloped his case – with kidnapping accusations included – every year between 100 and 150 Spaniards travel to France, Belgium, Germany, the Czech Republic and Switzerland to be treated with protons. It is a type of radiotherapy that has been in operation for more than 30 years in countries such as Japan and the United States and that, instead of using photons as conventional radiotherapy treatment, uses high energy protons. The characteristics of this type of particles, which are very heavy, allow them to be directed more precisely to the tumor, without hardly affecting the neighboring tissues.

“It is no more effective than conventional radiotherapy, but it is less toxic and has fewer side effects in the medium and long term,” says Carles Muñoz, director of Technology and Physics at the Catalan Institute of Oncology (ICO).

Proton therapy is especially indicated for tumours that are difficult to access or surrounded by vital structures, such as brain, head and neck tumours or ocular melanoma. Although “the clearest and indisputable indication is pediatric cancer and specifically brain tumors,” explains Andres Morales, director of the Pediatric Cancer Center at the Hospital Sant Joan de Déu in Barcelona.

“Until a few years ago we had children who were able to cure the gliomas they had but who died from other tumors that appeared 15 or 20 years later induced by conventional radiotherapy. With proton therapy, the risk of radiation-induced tumors is greatly reduced,” he adds.

“If you irradiate with protons, the side effects are significantly reduced, such as loss of cognitive function in children, endocrine alterations, growth or motor problems, and even serious early heart disease,” said Jordi Giralt, head of the Radiation Oncology Service at the Vall d’Hebron Hospital and head of the radiotherapy oncology group at the Vall d’Hebron Institute of Oncology (VHIO).

For this reason,” adds Giralt, “the international scientific community indicates that the treatment of choice in young children should be proton therapy. In Vall d’Hebron, children under the age of six with brain tumours and some types of soft tissue sarcoma, which are the two types of tumours that have the greatest benefit when treated with protons, we value referring them to centres abroad for treatment”.

In the absence of the necessary infrastructure to implement this treatment, a commission of radiotherapy experts from the public health system must evaluate each case. If it is decided that the treatment of choice is proton, then the patient is sent to centers located in European cities with specialized units to apply it. The price, according to the Spanish Society of Radiation Oncology (SEOR), is between 20,000 and 30,000 euros per patient and treatment, a figure at least five times higher than conventional radiation therapy, and is borne by the public health.

The rest of the expenses, such as transport, accommodation and meals during the month and a half of the average duration of the treatment, are paid by the families who sometimes have the help of foundations, such as Columbus, which offer them economic and logistical support.

“Right now not all cases of patients who could benefit from proton therapy are being sent abroad to be treated,” warns Carlos Ferrer, president of the SEOR. “In addition to the bureaucratic obstacles placed by the administrations to process each case, there are no clear recommendations for which tumors to apply proton therapy. In addition, sending a child or an adult out of Spain is a logistical problem, language, work for the family, so many doctors refrain from prescribing it.

For this reason, claims this radiotherapeutic oncologist, “it is absolutely necessary that Spain be equipped with proton therapy rooms” and remacha that “with the exception of Portugal, Greece and Spain, the rest of European countries have at least one room for every 10 million inhabitants.

“Private initiative is always more agile than trying to agree on 17 autonomies. The Social Security could continue to assume the cost of being treated in these centers, which would be similar to abroad, but the displacement of families would be avoided. Over time these two private units will increase the number of patients treated and that can make a public facility cost-effective,” Ferrer said.
In recent years in Spain there have been several public projects to roll out an infrastructure of this type, but “they have never been on the agenda of any administration.

In Catalonia, the new Sant Joan de Déu Paediatric Cancer Centre was contemplating having one of these facilities at an early stage. The problem is that “doubled the initial budget of the center, which was quantified at 30 million euros. A proton therapy center, taking into account the technology and infrastructure needed to house it, requires an investment of 50 million euros,” says Morales, who believes that it would make more sense a joint unit between several hospitals that would benefit a much larger geographical area.

In this sense, as La Vanguardia has learned, an alliance of Catalan public hospitals presented to the councillor Toni Comín a unitary project to create a proton centre that would attend both to patients residing in Catalonia and in its area of influence (Aragon, Navarre and Valencia). However, the political situation, according to the sources consulted by this newspaper, meant that the proposal came to a halt. “Everything was on the right track. Let’s hope the subject can be reprimanded soon”, they say.

According to Josep Maria Borràs, head of Catalonia’s Oncology Master Plan, “this is an issue that we have raised many times. Certainly the overall cost has been reduced considerably and is now more viable. And although it is a priority of the oncology plan, at the moment there is no project of this type on the table”.

The Ministry of Health, Consumer Affairs and Social Welfare had analysed the results of a report by the Catalan Agency for Quality Assurance and Health Assessment (AQuAS), which concluded that “proton therapy increases safety and efficacy for certain types of tumours”. And, according to sources from this ministry confirmed to the newspaper, the intention was to start working with the autonomous communities to include it in the portfolio of services in those indications where there is evidence. That was before the call for general elections for 28-A. The proton therapy, public, will have to wait again.