BASROC/CONFORM OPEN DAY 2009 At STFC Cockroft Institute Daresbury

1. Bleddyn Jones University of Oxford Gray Institute for Radiation Oncology & Biology 21 Century School Particle Therapy Cancer Research Institute, Oxford Physics. BASROC/CONFORM OPEN DAY 2009 At STFC Cockroft Institute Daresbury

2. CANCER…..the threat to humanity • 40% risk during lifetime…might even increase with global warming (thermodynamics) • Surgery, Radiotherapy, Chemotherapy can all be risky and permanently injurious……..no cause for complacency. • R/T 12% of NHS cancer budget; its provision regarded as inadequate internationally

3. Which form of technology would you like used to treat your cancer?

4. Development of Cancer Radiotherapy Most current radiotherapy uses High energy X-ray beams from linear accelerators or ‘linacs’ These X-ray beams pass through entire thickness of body Versatile: 3600 rotations, + imaging capabilities Modern Linac

5. Pristine Bragg Peaks of Selected Energies at FHBPTC Courtesy of H. Kooy, Ph.D.

6. Carbon Ion Beam Profile 20-30 times effect in peak c.f. plateau Bragg peak RBE 5-7 Peak is spread / scanned & diluted, so RBE is intermediate and varies with position in a patient. Plateau RBE 1.1

7. X-Rays or Protons/Ions 80 50 150 0 60 150 0 40

8. Orbital Rhabdomyosarcoma X-Rays Protons Courtesy T. Yock, N. Tarbell, J. Adams

9. International Scene • Japan: formed National Institute of Radiation Sciences 1957. • 1986 Decision to have C ion therapy • Commenced 1996 • Japan Government Science Policy Review 2006-2010 noted favourable results and need for science to contribute directly to health of population. • Emphasis on cancers that are difficult to treat and for a kinder form of radiotherapy • Japan will soon have 10 facilities, all protons + 3 C ions. Tariff of ~ $ 30,000 per course allowed.

10. Countries who used national Physics labs/projects to start Particle Therapy • Germany ……GSI….. Heidelberg University Hospital Synchrotron built close to German Cancer Research Institute • France…Orsay University Protons; GANIL (Caen) will host new IBA 400 MeV C cyclotron • Switzerland: large expansion at PSI (Villigen); development of spot scanning techniques. • Austria…..will use novel CERN cyclolinac system • Italy ….Pavia, synchrotron system • Stanford/USA ..plans for new high tech accelerator for C ions; twenty proton centres planned in USA.

11. We chose the wrong particle ….the neutron Physical Dose Neutrons would not be chosen today, we need the Bragg Peaks

12. 1 year 3 years 4 years 5 years Kidney Cancer : Stage I, TIa N0 M0National Institute of Radiological Sciences, Chiba, Japan carbon ions, 80GyE / 16fr. /4wks 治療前 Can radical surgery be avoided? Better cancer screening might create extra need to use physics solutions

13. Cancer of the oesophagus treated to 72 Gy -hardly any lung exposure in Japan: British plan 54 Gy only British X-rays three beams Protons two beams

14. Medulloblastoma in a child X-rays 100 60 10 Proton particles

15. The only working model in UK (funded by NHS doctor working during his holiday)

16. High LET optimum dose per fraction using calculus method Even for protons, treatments might be accelerated; Germany 19# Japan 16, 10, 4, 1 #

17. Following from Jones & Dale Int J Radiat Oncol Biol & Physics 1998 Inputs: Cell sensitivity: (dose + dose squared) Cell number Proliferation rate DNA Repair Dose to N Tissue [z] Dose to tumour [d] d=g z g is degree of sparing Cost of achieving low g (reciprocal) Cost per fraction Cost of failure to cure Cost of toxicity Fixed costs Poisson statistics Cost Model for Radiotherapy

18. Japanese Progress in Fractionation • 1 treatment only for small lung cancer • 4 treatments for prostate cancer • Most treatments in 12 -16 treatments over 4 weeks • Cost applied regardless of fractionation • Germany 19 fractions in 19 days at GSI • Protons in USA 4-8 (eye); to 38 fractions prostate/skull base.

19. Expected and achievable benefits Reduce fear of cancer treatment, improved patient experience Dose increase to cancer : 1% increase in cancer control per unit increase in dose …..i.e. 15 Gy extra 15% extra control Dose reduction to organs e.g. lung, brain, eye, spine, bowel, bone: leading to reduced or absence of many side effects Chemotherapy better tolerated Better quality of life, ability to contribute to society etc.

20. UK Position • Member of PARTNER, ULICE & ENVISION EU FP7 grants……totalling ~24 M Euro • Occupying a peripheral role…data collection, instrumentation, leadership skills, modelling. • PAMELA – could transform our position to be leader in terms of new technology, clinical efficiency, clinical policies/research, and opportunity for comprehensive radiobiology programme under our own guidance.

21. EMMARing SeeSmith: WE4PBI01  Electrons – at relativistic velocities approaching speed of light PAMELAParticle Accelerator for MEdicaLApplications • Clinical Requirements • PAMELA – status • Summary Protons, helium to carbon range of ions – at non-relativistic velocities

23. Main Clinical Requirements Treatment Plan should be determined by clinical need not limited by Accelerator Technology

24. Injector systems Double-helix coil - smart way of creating a cosine-theta magnet RF System Gantry/delivery systems

25. Choices cyclotron Proton Therapy 1 ring NSFFAG Carbon Therapy OR Proton Therapy Ring 1 NSFFAG 1 ring NSFFAG ring 2 NSFFAG Carbon Therapy

26. Next steps • Complete the proton ring design • Develop the carbon ring • Develop beam transport & gantry • Seek component prototype funding • Main ring magnets, RF, Kickers, Carbon RFQ • Seek machine funding • UK Demonstrator for CPT

27. Primary Liver cancer Primary liver cancer treated by carbon ions 5 year follow up in cured patient malignant melanoma 15 months after RT

28. Some PAMELA work on radiobiology of • Dose rate (and so dose duration) • Ion species • Throughput • Dose painting …new features N + C

29. Gantries • Heidelberg has huge 300+ ton gantry…… First in world • French seeking to use cryogenic s/c magnet to halve the weight • CONFORM system magnets within gantries offers best long term solution to gantry manufacture at lower tonnage, footprint and cost

30. 21 Century School Particle Therapy Cancer Research Institute, Oxford Since January 2009 our aims are to promote:- Education (Public, Professions and Policy Makers) Research [Physics, Biology and Medicine] Investment [NHS, Research Councils, Cancer Charities and Public] Advanced Technology Ion Treatment Facility in UK and elsewhere - including third world with cost optimisation.