International Journal of
Radiation Oncology biology
physics
www.redjournal.org
COMMENTS The Cost of Setting Up and Operating a Hadron Facility
also financially, the most attractive hadron facility remains a proton therapy center. Dirk De Ruysscher, MD, PhD Radiation Oncology University Hospitals Leuven Leuven, Belgium
In Regard to Vanderstraeten et al To the Editor: We read with interest the work of Vanderstraeten et al (1). They should be congratulated for estimating the cost of proton, carbon ion, or a combined proton and carbon ion facility. However, the analysis was based on several assumptions that cannot be sufficiently substantiated by the results of previous studies. First, the analysis and subsequent conclusions were based on the use of fixed beams for carbon ions instead of the use of gantries, whereas the costs for protons were based on the use of gantries, thus resulting in relatively higher investment costs for proton therapy in their comparison. On the basis of the available literature, it is not clear how the results obtained with fixed beamebased carbon ions relate to those obtained with gantry-based protons. Second, the conclusions from these authors are heavily determined on the assumption that hypofractionation is possible only with carbon ions rather than with protons. Indeed, the number of fractions for proton therapy was expected to be 30, whereas for carbon ions 15 fractions were presumed, which even decreased down to 4 fractions. Unfortunately, the authors did not provide any references to support the implicit assumption. Dosimetric and clinical data robustly show that protons can be delivered in hypofractionated schedules similar to those used for carbon ions (2). These theoretic considerations have been shown to be realistic in clinical studies. Indeed, hypofractionated regimens with protons have produced favorable outcomes in selected patients with lung, liver, and pancreatic cancers (3-7). The currently available data do not support the assumption that proton therapy cannot be effectively given with the same fractionation schedules as those used with carbon ions. The total costs of protons can thus be reduced considerably, compared with the assumptions of Vanderstraeten et al. Proton therapy remains the cheapest option for treating patients with hadron therapy, even when performed with a gantry. We thus believe that for quality reasons, but
Int J Radiation Oncol Biol Phys, Vol. 90, No. 1, pp. 238e241, 2014 0360-3016/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved.
Madelon Pijls-Johannesma, MSc, PhD CZ Health Insurance Company Tilburg, The Netherlands Joe Y. Chang, MD, PhD Radiation Oncology University of Texas MD Anderson Cancer Center Houston, Texas Johannes A. Langendijk, MD, PhD Department of Radiation Oncology University Medical Center Groningen University of Groningen Groningen, The Netherlands http://dx.doi.org/10.1016/j.ijrobp.2014.06.008
References 1. Vanderstraeten B, Verstraete J, De Croock R, et al. In search of the economic sustainability of hadron therapy: The real cost of setting up and operating a hadron facility. Int J Radiat Oncol Biol Phys 2014;89: 152-160. 2. Carabe-Fernandez A, Dale RG, Hopewell JW, et al. Fractionation effects in particle radiotherapy: Implications for hypo-fractionation regimes. Phys Med Biol 2010;55:5685-5700. 3. Register SP, Zhang X, Mohan R, et al. Proton stereotactic body radiation therapy for clinically challenging cases of centrally and superiorly located stage I non-small-cell lung cancer. Int J Radiat Oncol Biol Phys 2011;80:1015-1022. 4. Wang Y, Efstathiou JA, Lu HM, et al. Hypofractionated proton therapy for prostate cancer: Dose delivery uncertainty due to interfractional motion. Med Phys 2013;40:071714. 5. Chang JY, Komaki R, Wen HY, et al. Toxicity and patterns of failure of adaptive/ablative proton therapy for early-stage, medically inoperable nonsmall cell lung cancer. Int J Radiat Oncol Biol Phys 2011;80:1350-1357. 6. Westover KD, Seco J, Adams JA, et al. Proton SBRT for medically inoperable stage I NSCLC. J Thorac Oncol 2012;7:1021-1025. 7. DeLaney TF. Proton therapy in the clinic. Front Radiat Ther Oncol 2011;43:465-485.
Radiation Oncology biology
physics
www.redjournal.org
COMMENTS The Cost of Setting Up and Operating a Hadron Facility
also financially, the most attractive hadron facility remains a proton therapy center. Dirk De Ruysscher, MD, PhD Radiation Oncology University Hospitals Leuven Leuven, Belgium
In Regard to Vanderstraeten et al To the Editor: We read with interest the work of Vanderstraeten et al (1). They should be congratulated for estimating the cost of proton, carbon ion, or a combined proton and carbon ion facility. However, the analysis was based on several assumptions that cannot be sufficiently substantiated by the results of previous studies. First, the analysis and subsequent conclusions were based on the use of fixed beams for carbon ions instead of the use of gantries, whereas the costs for protons were based on the use of gantries, thus resulting in relatively higher investment costs for proton therapy in their comparison. On the basis of the available literature, it is not clear how the results obtained with fixed beamebased carbon ions relate to those obtained with gantry-based protons. Second, the conclusions from these authors are heavily determined on the assumption that hypofractionation is possible only with carbon ions rather than with protons. Indeed, the number of fractions for proton therapy was expected to be 30, whereas for carbon ions 15 fractions were presumed, which even decreased down to 4 fractions. Unfortunately, the authors did not provide any references to support the implicit assumption. Dosimetric and clinical data robustly show that protons can be delivered in hypofractionated schedules similar to those used for carbon ions (2). These theoretic considerations have been shown to be realistic in clinical studies. Indeed, hypofractionated regimens with protons have produced favorable outcomes in selected patients with lung, liver, and pancreatic cancers (3-7). The currently available data do not support the assumption that proton therapy cannot be effectively given with the same fractionation schedules as those used with carbon ions. The total costs of protons can thus be reduced considerably, compared with the assumptions of Vanderstraeten et al. Proton therapy remains the cheapest option for treating patients with hadron therapy, even when performed with a gantry. We thus believe that for quality reasons, but
Int J Radiation Oncol Biol Phys, Vol. 90, No. 1, pp. 238e241, 2014 0360-3016/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved.
Madelon Pijls-Johannesma, MSc, PhD CZ Health Insurance Company Tilburg, The Netherlands Joe Y. Chang, MD, PhD Radiation Oncology University of Texas MD Anderson Cancer Center Houston, Texas Johannes A. Langendijk, MD, PhD Department of Radiation Oncology University Medical Center Groningen University of Groningen Groningen, The Netherlands http://dx.doi.org/10.1016/j.ijrobp.2014.06.008
References 1. Vanderstraeten B, Verstraete J, De Croock R, et al. In search of the economic sustainability of hadron therapy: The real cost of setting up and operating a hadron facility. Int J Radiat Oncol Biol Phys 2014;89: 152-160. 2. Carabe-Fernandez A, Dale RG, Hopewell JW, et al. Fractionation effects in particle radiotherapy: Implications for hypo-fractionation regimes. Phys Med Biol 2010;55:5685-5700. 3. Register SP, Zhang X, Mohan R, et al. Proton stereotactic body radiation therapy for clinically challenging cases of centrally and superiorly located stage I non-small-cell lung cancer. Int J Radiat Oncol Biol Phys 2011;80:1015-1022. 4. Wang Y, Efstathiou JA, Lu HM, et al. Hypofractionated proton therapy for prostate cancer: Dose delivery uncertainty due to interfractional motion. Med Phys 2013;40:071714. 5. Chang JY, Komaki R, Wen HY, et al. Toxicity and patterns of failure of adaptive/ablative proton therapy for early-stage, medically inoperable nonsmall cell lung cancer. Int J Radiat Oncol Biol Phys 2011;80:1350-1357. 6. Westover KD, Seco J, Adams JA, et al. Proton SBRT for medically inoperable stage I NSCLC. J Thorac Oncol 2012;7:1021-1025. 7. DeLaney TF. Proton therapy in the clinic. Front Radiat Ther Oncol 2011;43:465-485.
