mixed blessings

Surely by now you've heard the tragic tale of the Wal-Mart employee in Valley Stream, Long Island in New York City who was literally trampled to death by crazed shoppers who'd camped out all night for the big post-Thanksgiving Day sale. Poor Jdimytai Damour didn't stand a chance against the marauding hordes who surged through the doors moments after he opened them. He fell. No one noticed as they stomped right over him. Nor did they notice the pregnant woman who was also injured by the jostling crowd (she escaped with minor injuries and her unborn baby survived). Even as paramedics were working madly to save Damour's life, the shoppers kept right on shopping -- in fact, they "became irate" when the Wal-Mart store management announced it was closing the store on account of the man's death. I guess life is cheap when your sole focus is snagging that long-coveted Wii at a low, low price. Just think how much more it will mean to your children knowing that you spilled innocent blood to get it for them.

So "Black Friday" turns out to be a very apt moniker indeed, especially when you count the two men shot at a Los Angeles Toys 'r Us the same day, or this video showing crazed shoppers grappling like mad over what must be the last available X-Boxes on the planet, given their desperation. People, it doesn't have to be this way! It's possible to shop for great deals without behaving like rabid animals. The Spousal Unit and I are in Vegas for Thanksgiving weekend, and there are some awesome sales here, too. I managed to purchase a very nice Cavalli off-the-shoulder sheath dress and black clutch purse for 40% off without getting into a catfight over it, or killing anyone who got in my way. Shopping shouldn't be an extreme sport.

The ugly news was in such sharp contrast to the generous, welcoming atmosphere of the dinner we attended on Thanksgiving itself, hosted by a lovely woman who has made an annual tradition of opening her home to an extended family of "holiday orphans": LA residents who (for many reasons) don't spend the holiday with family of their own. Everyone brings a specialty dish for the feast, and after dinner, folks go around the table -- or tables, in this case, set end to end, since we numbered 32 -- saying what they were most thankful for. The two people seated to my immediate right were both cancer survivors; they were thankful to be alive. You'd never find them beating the crap out of another shopper for the last X-Box. There's nothing like a brush with death to bring what's really important into the proper perspective.

I occasionally write about cancer treatments from time to time; there's so much cutting-edge research going on, so many different approaches to treatment. We're literally throwing everything but the kitchen sink at the problem, and while we might not have discovered a miraculous "cure," survival rates are the best they've ever been -- and I had the dinner companions to prove it. (Joanne, the Spousal Unit's co-blogger at Cosmic Variance, also survived a bout with breast cancer -- and a minor melanoma for good measure -- this past year. Go, Joanne!) There are new surgical techniques, better chemotherapy drugs, a controversial new CyberKnife to treat prostate cancer, ongoing research into using nanoparticles to literally burn away tumors without harming surrounding healthy tissue, post-surgical x-ray radiation -- and, increasingly, proton therapy. 

Most people know -- should they stop to think about it -- that x-rays are a form of ionizing radiation: they are of sufficient energy to damage and destroy cells -- specifically, it damages DNA and other genetic material, thereby interrupting vital cell functions -- which is why exposure even for medical/dental purposes is carefully controlled and kept to a minimum. X-rays can target cancer cells and prevent the out-of-control growth that invariably leads to death when untreated.

Proton therapy works on similar principles. Physicist Robert R. Wilson first suggested in 1946 that the energetic protons produced at the Harvard Cyclotron Laboratory (HCL) might be an effective cancer treatment, and in fact the very first such treatments were performed at particle accelerators originally built for physics research: Berkeley Radiation Laboratory in 1954, and Uppsala in Sweden in 1951. HCL and Massachusetts General Hospital provided proton therapy to nearly 10,000 patients between 1961 and 2002, when the old cyclotron was finally shut down. Proton therapy continues at the hospital, however, this time via the Francis H. Burr Proton Therapy Center.

So proton therapy has been around for about 50 years, and yet it remains an uncommon treatment for cancer, generally reserved for the most complicated cancers, such as tumors in the head, eyes, or neck that have not yet spread to distant areas of the body -- locations where collateral damage to surrounding tissue could have serious consequences. To date, fewer than 20,000 Americans have been treated with proton therapy, and there are five operating treatment centers in the US (Boston; Loma Linda, CA; Bloomington, IN; Houston, TX; and Jacksonville, FL). There are 25 proton therapy centers operating worldwide, having treated some 40,000 patients to date.

But that uncommonality might be changing, according to MassGen's Jay Flanz, who was among the featured speakers at the Industrial Physics Forum I attended in Boston in October. (Yes, I am only now getting around to blogging about it. I've been busy with this little thing called the Science and Entertainment Exchange -- which now has its own Facebook page, by the way, so become a fan today!) Several new centers are in the advanced planning stage, slated to come online between 2010 and 2012.

Why the sudden demand for what is actually a pretty old technology? Well, proton therapy offers some very real benefits over conventional x-ray radiation therapy: very few side effects, and carefully targeted radiation with almost no damage to surrounding healthy tissue. In conventional x-ray therapy, the x-rays travel through the body and deliver radiation to all the tissues along the way to the actual tumor -- hence the side effects. To cut down on the damage to healthy tissue, doctors usually limit the dose delivered to the tumor. But proton beams actually deposit almost all their energy to the tumor itself, with very little damage to surrounding tissue -- so the side effects are minimal. That's why it's been used so successfully to treat ocular (eye) cancers, brain tumors, spinal tumors, and so forth, now expanding to treat some prostate and breast cancers as well.

That said, proton therapy has its downsides too, namely, size and cost. It takes a 222-ton particle accelerator housed in a football-field-sized building with walls up to 18 feet thick in order to shield the outside world from harmful radiation. Such facilities come with a very high price tag: more than $100 million, sometimes as much as $200 million. Some researchers have argued that the benefits to be gained aren't significant enough to justify the cost of these large facilities. Proton therapy is vital for treating certain rare tumors that conventional x-ray therapy can't effectively treat, they say, but it only matches the success of x-ray therapy for other cancers -- yet it costs twice as much.

Granted, there is a certain cache to having the hot new medical technology on hand. An article in the New York Times a year ago made reference to "an arms race mentality" among medical centers eager to add proton therapy facilities. It cited experts who feel the growing popularity of proton therapy "reflects the best and worst of the nation's market-based health care system, which tends to pursue the latest, most expensive treatments -- without much evidence of improved health -- even as soaring costs add to the nation's economic burden." The same article compares proton therapy to MRI machines, now "accepted staples of medical practice, [but] there is still concern about their overuse and the impact on medical spending."

Now, I'm sympathetic to the high cost of quality health care -- as a freelancer, I spent a huge fraction of my career without health insurance, so I know how steep those costs can be -- and I would not advocate pointless tests or treatment. That said, I think almost no side effects with no diminishment of effectiveness in killing tumors is a substantial benefit of proton therapy, and worth the risk of abuse by unscrupulous sorts who would overprice medicine just to turn a profit. Who needs the nausea, vomiting, diarrhea ad weakened immune system? I challenge anyone to find a prostate cancer patient thrilled about the very real prospect of becoming impotent as a side effect of conventional radiation treatment. And children are especially sensitive to the side effects of radiation; who would begrudge a child with cancer a kinder, gentler alternative? In much the same way, the use of MRI can detect breast cancer earlier than conventional mammograms or self-exams, and early detection means better chances of successful treatment and long-term survival. Just ask Joanne at Cosmic Variance. I bet she thinks the MRI that caught her breast cancer was worth every extra penny.

Flanz argued in favor of expanding the availability of proton therapy, citing not just the lack of side effects but also a lowering of the costs associated with the construction -- in part because where once the equipment had to be fabricated piece by piece, commercial companies now exist that can build new facilities from the ground up. Even better news: the size of the machines is decreasing as well. Last year scientists at the UC-Davis Cancer Center announced that they had licensed the technology for the first compact proton therapy system to TomoTherapy, Inc. in Madison, Wisconsin.

Basically, the Livermore scientists figured out how to accelerate protons to high energies with a light-weight insulator-based structure that doesn't require heavy (and pricey!) magnets to bend and steer the beams. The system also has the ability to vary the energy, intensity, and "spot" size of the proton beam. It produces radiation in rapid pulses so that only small "spots" of radiation are delivered throughout the tumor, for highly precise destruction and (again) minimal damage to surrounding healthy tissue.

The technology actually came out of defense-related research at Lawrence Livermore National Laboratory for nuclear stockpile stewardship purposes, and it means proton therapy can realistically be cut down to size in both scale and price (costing one-fifth as much as a full-scale machine, around $20 million), thereby putting the technology within the reach of any major cancer center. TomoTherapy plans to develop and test the first clinical prototype at the UC-Davis Cancer Center, and then move to bring the machines to market if that initial clinical testing proves successful.

Proton therapy might have its naysayers, and some of their objections might, indeed, be valid. But for the patients who ultimately benefit, it bestows the gift of continued life -- and who can put a price tag on that? It's way better than snagging the last Wii on sale at Wal-Mart.

Comments

[Chris]

Slight tangent, but have you seen this? http://www.cbsnews.com/stories/2008/04/10/60minutes/main4006951.shtml
It's some story/info about a guy who came up with a radio wave based therapy for cancer

this proton therapy sounds pretty interesting, too

[Daily Physics]

Proton therapy is a great application of physics. It shows how physics research has a direct improvement on the quality of life of a person. Nice one.

[JoAnne]

Great piece, Jennifer. Proton therapy holds much promise and it's great news that compact systems are being built! Plus, there's nothing better than a direct application of particle physics to medical science.

Regarding the cost, let's weigh in the fact that treating cancer patients is already insanely expensive. Totalling my medical costs over the last year shows that my insurance company was billed roughly $1,000,000 to keep me alive - half of that was for the chemo alone. And, my care would have been even more extensive and expensive, if the cancer had not been caught when it was by that MRI (which the expletive-deleted insurance company balked at BTW). So sure, proton therapy is expensive, but if it replaces some traditional therapy that is also expensive, then the figure of merit is the scale of the additional cost. And that will decrease as technology improves.

Personally, I don't feel like a cancer survivor yet. Right now I feel like a survivor of the cancer treatment, but will have to wait a few years to see whether I am a true survivor or not...in the meantime I hope to live some of the lessons I learned after being faced with the very real possibility of my own untimely death.