The proton bombardment that cures the most hidden tumors arrives in Spain

Entrevista a Arantza, madre de un niño de dos años y medio al que le prescribieron protonterapia para el tumor del pequeño y que ha sido derivado a Alemania para la operación. 17/12/2018 – ARABA PRESS – Barakaldo, País Vasco
The world

The new radiation therapy with protons to fight cancer has already begun to be installed in two Spanish hospitals. It is more effective, less toxic and will be available for more complicated tumors in a few months. The era of proton therapy begins.

A brain tumor forced Arantza to pack and travel more than 2,000 kilometers to Germany so that her little Diego could receive the most advanced generation of radiotherapy. The boy was only two years old and the doctors saw it clearly. They had to discard conventional radiation and bet on a very promising modality that in Spain will land at the end of 2019: proton therapy.

The same prescription was made to Fermín, a 49-year-old man with a tumor at the base of his skull. He had no choice but to travel to Pavia (Italy) to access what was already the only possible way of treatment.

Thanks to proton radiation, the incidence of second tumors in children like Diego can be reduced by up to 30%. When entering the body, argues Carlos Ferrer, president of the Spanish Society of Radiation Oncology (SEOR), «these particles practically do not release radiation until they reach the lesion». There they discharge all their concentrated energy with the mission of killing the maximum number of malignant cells without damaging surrounding tissues. Therefore, doctors define it as «the radiation of the future in the XXI century»

GOGO LOBATO | THE WORLD
I WAS ON MARCH 15, 2017 (THE DAY OF MY BIRTHDAY) TO A CENTER OF PAVIA (ITALY), WITHOUT KNOWING WHAT I FACED, AND THERE I PASSED TWO MONTHS AND A HALF. TODAY, I AM STABLE AND THE TUMOR HAS BEEN REDUCED
By not ‘touching’ healthy areas, sequelae such as «decreased neurocognitive function, alterations in growth, motor capacity or severe forms of early heart disease are prevented,» explains Felipe Calvo, a specialist in Radiation Oncology at the University Hospital of Navarra. (CUN)

A technological virguería that is managing to reduce the rare tumor (chordoma) of Fermin. According to his radiation oncologist, María José Ortiz Gordillo, «he was in a place that was difficult to access, and his complete removal was complicated because being surrounded by vital structures could cause his death.» Surgery could not be used, nor could the photons of classical radiotherapy. «The doses necessary to be effective would be well above the safe ones and this could cause irreparable damage such as visual problems, intellectual and behavioral disorders, alterations in language and memory, in the ability to swallow or close the eyes , among others». For these reasons, the medical team of the Virgen del Rocío University Hospital in Seville opted to refer him to a center located in Pavia (Italy) where proton therapy was applied. Its lower toxicity allows to increase the dose in the tumor when necessary, thus achieving greater local control of the disease, without damaging healthy tissues.

«I left on March 15, 2017, the day of my birthday, without knowing what I was facing, and there I spent two and a half months,» says Fermín. The established plan included 35 sessions and according to his doctor, «we are checking in the control resonances that we do periodically that the volume of the tumor is getting smaller and the patient is stabilized». As the effect is not immediate and months pass until some cells die, «greater regression in Fermín’s tumor can still be expected», clarifies the specialist.

Expectations are high. Ortiz Gordillo recalls another patient who also had a chordoma. I was eight years old. «He was in a coma for three months, there was no hope, we referred him to Paris, and after treatment with proton therapy, he is now free of the disease.» So is Ashya King, a British boy who jumped into the media in 2014. Far from accusations of kidnapping for taking him out of the hospital where he was hospitalized pending conventional radiation, the intention of his parents was to travel to Prague to be able to provide him proton-based radiation.

His confidence in proton therapy was maximum. The success of this treatment has a reason for being. Its particles are much heavier than the photons of classical radiation, so they can be directed much better and do not suffer alterations in their trajectory. «We can stop the radiation wherever we want and especially sculpt the tumors that are near structures or organs very sensitive to radiation, for example: optic nerves, brain, spinal cord, kidneys, especially in pediatric patients, whose organs are in development and they are even more sensitive, «says radiation oncologist Raimon Miralbell.

Arantza, with Diego, two years old, recently submitted to proton therapy in Germany. ARABA PRESS
THE RADIATION SESSION LASTED FIVE MINUTES, BUT UNTIL THE HOUR AND A HALF WAS NOT AWAKENED, WHICH WAS WHEN I WAS ADVISED SO THAT I COULD ACCOMPANY MY SON
ArantzaMore precise, safer and more effective. This is how the experts describe this revolutionary technology, which at the moment only includes 58 centers around the world that have treated about 140,000 patients. In Spain, after the favorable report of the Nuclear Safety Council (CSN) last September, two private groups have gone to work in the construction of two specialized units. Quirónsalud plans to open at the end of 2019 and the University of Navarra Clinic (CUN) will start treating patients with this technology at the beginning of 2020.

Felipe Calvo, who will co-direct the unit of the CUN, explains that proton therapy «produces great intensity of radiation by multiple molecular impacts in the selected area, depositing its effect in successive layers of the tumor in a very fast way, thus achieving the devitalization of the tumor and protecting healthy surrounding tissues. » In most cases, it does so in a few seconds, a little less than a minute. The rest of the time of each session (about 25 minutes) is used for placement and positioning of the patient guided by image. A scanning system allows the doctor to apply the most appropriate dose in each area to be treated.

The clinical histories of Diego and Fermín were those in which there was no doubt that it was best to refer the patient to another country where this therapeutic option known to attack only the tumor and not around it was available. «The doctors explained to us that Diego was very small and the classic radiation could have irreversible consequences in the mobility, the capacity of the speech, etc.», remembers Arantza.

The number of people who, like Diego and Fermín, have received proton therapy outside our borders by medical indication is unknown, but «it is estimated that between 2% and 11% of those who are going to receive radiotherapy would be susceptible to radiation. based on protons, «says the president of the SEOR.

However, «not all cases are being sent,» says Ferrer, who clarifies that «the decision to approve the treatment has to be approved by the corresponding counseling and would help a lot if we had a scientific consensus document as a guarantee where indicated in what assumptions proton therapy should be the treatment of choice ahead of classical radiation. » At this time, adds the expert, «from the SEOR we are working on it and probably present a guide of recommendations next March.»

According to the American Society of Radiation Oncology (ASTRO), the superiority of proton radiation is demonstrated in ocular tumors, those located at the base of the skull, in the spinal cord, in patients with genetic syndromes at risk of high toxicity, selected cases of reirradiation and also the pediatric ones (cerebral, base of the skull, neck, lung, ocular melanoma, liver, lymphoma and sarcomas).

As the scientific evidence grows, the list of indications will increase. Currently, its application in breast, prostate, pancreatic, pelvic, lung and esophagus tumors, among others, is under study. In France, for example, the New Approaches in Radiotherapy team of the National Center for Scientific Research (CNRS) has observed 70% of cures in glioma bearing animals with proton therapy. The main researcher of this work, Yolanda Prezado, predicts that «in three or five years a first patient with glioblastoma multiforme may be treated in a clinical trial».

In the words of Ferrer, «as the list of indications increases, the technology is miniaturized and costs are reduced, probably in less than 10 years, this tool can be incorporated in all the radiotherapy centers of the world, as a tool, not for replace radiotherapy. » At the moment, 45 units of proton therapy are under construction around the world. Years ago, it could mean the disbursement of 150 million euros. Now, around 40 million. In the words of Rafael Arranz, specialist in Radiophysics at the Virgen Macarena Hospital in Seville, «a unit costs about two kilometers of highway.» Or «the equivalent to the employee in drugs in a year in a service of Medical Oncology», underlines Consuelo Guardiola, a researcher at the National Center for Scientific Research in France.

Both Quirónsalud and the CUN have invested some 40 million in their new projects. Good , especially taking into account that as soon as they are put into operation, it will no longer be necessary to refer patients out of the country. The treatment will continue to cover the National Health System (between 18,000 and 25,000 euros), but those affected will no longer have to leave their family, to drive in an unknown city, with a different language, in a house that

It is not yours and also supporting the expenses of travel, air tickets, accommodation and meals. A number of reasons «stress that add to the cancer you’re facing at that time,» says Fermín.

Diego was taken to Germany by his mother and grandmother. He missed his father and his eight-year-old sister, their environment, their language, their home … «They had to give him 30 sessions and we were from September 26 to November 16 (2018) away from home. all, my husband stayed in Spain with our daughter Daniela. »

Every day, from Monday to Friday, they anesthetized Diego to keep him quiet. «Before, I had to be fasting for six hours and they could call you from 7:30 am to 4:00 pm The radiation session lasted about five minutes, but until the hour and a half did not wake up, that was when they told me so I could accompany my son, «says Arantza. «In about six weeks we have a resonance to see how the treatment worked.»

In Arantza bills, the price of proton therapy was 29,000 euros, 7,000 for anesthesia for children under seven years and pediatric oncology costs were 6,000 euros. Everything, paid for by the Spanish National Health System. The rest, «supermarket, travel, plane, accommodation, we assume, around 3,000 euros.»

The two new specialized units of Quirónsalud and Clínica Universidad de Navarra will avoid these disorders. However, «they will not be enough to cover the number of patients estimated to benefit,» according to the president of the SEOR.

Radiotherapy protons. Indications
As stated by Isabel Gallardo, professor of Nuclear Physics at the University of Seville, «if a restrictive use of proton therapy is used, around 1,000 patients a year will benefit (pediatric tumors, some brain, skull base, eye and spinal). » Taking into account that, according to the radiophysicist Arranz, «each room covers the therapy of about 275 people every 365 days» and that between the two Spanish private centers there are three, «another room would be needed».

If «we also include patients in whom local control can be improved by escalating doses, such as in lung cancer, breast cancer, some lymphomas, genitourinary tumors, etc., we would have some 20,000 people who, instead of receiving radiotherapy, would undergo proton therapy. «, Guardiola points.

The specialists consulted by this newspaper agree on the need to promote more units of proton therapy in Spain. As Guardiola points out, «it would be advisable to promote the installation of a public center that does not exist.» In the last five years there have been some attempts, in Barcelona, ​​the Valencian Community, Murcia, Madrid and Andalusia, but they have been frustrated again and again » .

The reasonable, points out Felipe Calvo, would be that «a technology with such benefits extends to the more patients better.» It depends on having between five and 10 units of active protons to confirm that the performance is large and no problems of access are created » .