Spain is joining a global race to adopt proton beam therapy, a form of cancer treatment hailed as a less-aggressive alternative to conventional X-ray radiation.
Two private hospitals are building facilities in Madrid; the first one is due to open in the last quarter of this year, and the second one in March 2020. Meanwhile, a scientific society has just issued guidelines to “fill a void” in the use of proton therapy in Spain, and a small group of independent doctors has created a second-opinion network to raise awareness about an option that they say patients are rarely told about because of hospitals’ own business interests.
A worldwide boom
Proton therapy received widespread media attention in 2014 when a little boy named Ashya King was taken out of a UK hospital by his parents against their doctors’ advice to seek treatment in Prague after first fleeing to Spain.
In 2014 the parents of Ashya King took him out of Southampton General Hospital in the United Kingdom against his doctors’ advice to seek proton therapy treatment in Prague. The family first fled to southern Spain, where they were held for 72 hours. Ashya, who suffered from a brain tumor, eventually received his treatment and in March 2018 he was declared free of all signs of cancer.
The following month, proton therapy was administered for the first time in the UK at a new private facility in Newport, South Wales. The National Health Service has since opened a unit at the Christie NHS Foundation Trust in Manchester, and is building another one at University College London Hospital (UCLH) NHS Foundation Trust, scheduled to open in the summer of 2020.
Facilities have boomed worldwide in the last decade, propelled by shrinking technology and lower investment costs. By the latest count there are more than 20 proton treatment centers in Europe and 27 in the United States, with many more in the pipeline. And some industry sources say the current global figure of around 60 could double in the next five years.
Quirónsalud, Spain’s largest hospital group, is building the country’s first proton therapy center in Pozuelo de Alarcón (Madrid) at a cost of around €40 million. And Clínica Universitaria de Navarra (CUN), the hospital of Spain’s prestigious University of Navarra, is opening another center in Madrid after investing a similar amount of money and shipping in Hitachi equipment from Japan. While the upfront costs are high, they are still significantly lower than the approximately €200 million that would have been required just a few years ago.
Who could benefit?
Supporters of proton therapy note that the technology has been used for decades, and that it is the clear choice in pediatric tumors and those near highly sensitive spots such as the brain, spinal cord or eyes. This is because the beams of proton particles zero in on the tumor with great precision, causing little radiation to the surrounding healthy tissues, and lowering the risk of developing new malignancies. In “classic” radiotherapy with photons, the beams continue to release energy as they cross the body.
According to the American Society of Clinical Oncology (ASCO), up to 60% less radiation can be delivered to the healthy tissues with proton beams, which may also allow for a higher dose to the tumor itself while avoiding the more severe side effects of conventional radiotherapy.
This makes it a particularly good choice for children “because you preserve their normal tissues better, and since children are probably going to be long-term survivors, you need to minimize any possible side effects of long-term treatments,” says Dr Felipe Calvo, who will head the new proton therapy unit at CUN. This “dosimetric advantage” also benefits patients with tumors near sensitive organs that could be damaged by collateral radiation, and those requiring re-irradiation in a previously treated area.
The scientific community is still divided over the superiority of proton therapy for more common malignancies such as prostate or breast cancer, and some experts suggest more clinical trials are needed to recommend a treatment whose cost per patient runs into the tens of thousands of euros. Critics point to the US, where patients have had trouble getting their insurance to cover some forms of proton treatment due to this lack of consensus, although studies are underway that could soon expand the current range of indications.
On March 14, the Spanish Association of Radiotherapy and Oncology (SEOR) issued new recommendations to “fill the void” in a country “with no prior guidelines for the use of proton therapy, a void that has not been filled by central or regional health authorities even though a good number of patients get sent for treatment outside our borders every year.”
Traveling for treatment
Some Spanish patients who have had negative experiences with traditional therapy have decided to try proton treatment even if, for now, it means going abroad. J. L. was diagnosed with lung cancer in October 2017, and underwent several cycles of chemotherapy as well as 40 sessions of radiotherapy. This caused him terrible side effects, including pneumonitis and esophagitis that required hospitalization.
“At that moment, we began searching for alternatives and discovered proton therapy. We contacted the Rinecker Proton Therapy Center in Munich and decided this could be the solution we were looking for.” He and his wife are planning to travel to Germany to try a treatment “without the undesirable side effects of conventional radiotherapy, which ravages your body.”
The technology involves a particle accelerator known as synchrotron or cyclotron that speeds up protons, creating high energy. A gantry system guides a moving beam to irradiate the tumor from different angles while the patient remains immobile on the treatment table.
The first treatments were performed in the 1950s with enormous particle accelerators used for physics research. The recently deceased James S. Slater was instrumental in the creation of the world’s first hospital-based proton beam center in 1990 at Loma Linda University Health in California, which remained the only center to offer proton therapy in a hospital setting until the early 2000s.
There are no reliable figures on how many Spanish patients are going abroad for treatment, either privately or through the public health system. In Spain, powers over healthcare are devolved to the regions, which are in charge of decisions regarding treatment and cost coverage. A Health Ministry spokeswoman said that public healthcare patients who are approved for proton treatment are being sent to nearby countries such as France.
SEOR president Carlos Ferrer says there were several attempts to develop public centers in Spain in the past, but “they never gelled because the technology was expensive at the time, and there wasn’t as much consolidated evidence as there is now. And then the economic crisis hit and everything came to a standstill. We should be grateful that the private sector is pushing this forward; if not for these initiatives, Spain would be at the same level as Portugal or Greece.”
Last December, the right-of-center Popular Party (PP) and Ciudadanos (Citizens) party rejected a budget amendment that would have earmarked €21 million to help create a public proton center in the Madrid region. One month later, Ciudadanos said it would push for a national proton treatment center. In the meantime, Quirónsalud and CUN say they are open to treating patients from the public health system through agreements.
Patient vs hospital
Dr Martin Edlinger, who runs his own private practice in Alicante province, believes there are additional reasons why proton therapy is still not widely known about or recommended in Spain. “It is purely for economic reasons. No oncologist, unless he or she is self-employed, is allowed to send patients somewhere else if the cancer treatment available at their own hospital makes a profit and is legal,” he says. “Diagnosis is often calibrated to the needs of the hospital.”
Edlinger has teamed up with several other practitioners from Spain and Portugal to create a second-opinion network called Consilium and a website offering information, “because there is a real need for independent answers when people are badly ill and confronted with an operation or life-threatening treatment.”
“I would never recommend proton therapy if not convinced 100% that it was the best choice for a patient at that moment,” says Edlinger. “But people should at least know their options.”
Needs in Spain
The SEOR, using “conservative criteria based on experience in European countries such as the Netherlands or Italy,” has calculated that in the short term, between 750 and 1,000 people a year could benefit from proton therapy in Spain, but this figure could grow to around 17,000 as the evidence consolidates. “Right now it means that Spain needs three treatment rooms, a number that could progressively grow.”
Calvo, of CUN, notes that these units, known technically as Unique Scientific and Technical Infrastructures (ICTS), are so expensive and require so many highly trained personnel, that it is unlikely that Spain will experience a sudden explosion of centers the way that countries such as the United States have. “I think there will be more of them, but not by the dozens or hundreds. There also needs to be an element of innovation and research involved in this kind of investment: it doesn’t make sense to simply do what wealthier countries were already doing 20 years ago.”