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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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Source: Forbes Website

Main Hardware

Components of

Proton Therapy

S.Tohoku Layout

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Bragg Peak

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Passive Scattering

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Collimator (Brass)

Compensator (Lucite)

Active Scanning

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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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Why ‘low dose’ Regions are Important

Ionising Radiation Causes Cancers!

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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

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NCCS PTC

• Currently in planning/design phase

• Target: treat first patients 2017/2018

• 4 Gantry rooms

• An experimental beam line depending on

interests

Thank you