Proton vs. Conventional Radiation

Why are protons so much more precise? (My understanding)

I'm comparing proton radiation with conventional, photon or xray, radiation. I've also seen some literature about carbon radiation, but have not had a chance to research it and know too little about it to comment here.

Protons are more precise primarily because they are "particles". Conventional radiation uses "waves". Waves of energy move through human tissue and cannot be stopped. On the other hand, protons can be "stopped" by firing them into tissue of known density at a speed that will cause them to slow down and stop at a precise point. Beyond that, protons do not give off much of their energy until they stop. Then, they give it all up in a hurry. On the other hand photons, (conventional radiation), give up most of their energy as soon as they encounter human tissue. Then they keep right on going and exit out the other side. See the graph below.


Pretend that the "Depth in Water" is the "Depth in your Body". It's close enough to make the point. Imagine that the Y-axis represents your skin where the radiation enters your body. As you go further to the right on the X-axis, you are moving deeper into your body.

The first curve you see is the photons or conventional radiation. Note that they give up most of their energy, (read - 'radiate the tissue'), within the first two centimeters of entering your body. Then, they continue doing so at a lesser and lesser level all the way through your tissue until they finally exit the other side.

The next four curves represent protons. Note that they give off very little of their energy, or radiation, until they get to their programmed depth and then they 'explode' and die. Note especially that they are not going out your back. The way the doctors and physicists cover the whole target is to 'laminate' or 'stack' the proton beams so that they each stop at the appropriate depth to cover the entire target.

There are a couple of terms here that are used in the profession. "Entry Dose" and "Exit Dose".

Note that with conventional radiation, there is a huge entry dose and that is probably not where the target is. Then the energy is largely dissipated before ever reaching the target and it keeps on giving off radiation or energy until it passes out of your body. That's the exit dose.

With the protons there is an entry dose, but it is very low by comparison. As the protons get close to their target and begin to slow, you can see that they very rapidly give up all of their energy and then die. They do not keep going out the other side of your body. No exit dose at all.

That means that the explosion of energy or radiation is concentrated on the target. In this case, the target is your cancer. Because of those curves, known as Bragg Peaks, you can see that they are able to concentrate much higher doses of radiation right on the target without affecting nearby tissues.

Kill, Fang, Kill!!!

Why Protons?

Why choose proton therapy over any of the others? Proton therapy is not the right choice for everyone, for a lot of reasons, but for me it quickly became the only choice after I found out about it and did some further research.

The primary drawback to proton therapy is that a person must be willing to wait to get it. The availability is severely limited at present because there are only five centers available in the US. Many people can't stand the thought of waiting a month or two with cancer growing inside them and I can surely understand that. For them, one of the other options would be better.

Other drawbacks, it is extremely expensive (most insurance does cover it to some extent), and the centers are spread across the country. If you aren't lucky enough to be in a town that has one, you'll be traveling, be away from family and friends for two months, and have the additional expense of finding somewhere to live for those months.

On the plus side, proton therapy is extremely precise. For prostate cancer it has at least an equal cure rate as, "The Gold Standard", which is radical prostatectomy, standard or robotic. The kicker is that it has almost no incidence of side effects. The primary side effects that can be experienced in any of the treatments for prostate cancer are incontinence and impotence, either of which can have a marked impact on a guy's quality of life.

The next post will explain, as best I can, why proton therapy can be so much more precise than conventional radiation.

UF Proton Therapy Institute - Interesting Factoids

Florida Proton was built from the ground up as a radiation treatment center. They are primarily a proton center, but also provide state of the art treatment with conventional radiation as well.

This is a diagram of the treatment equipment. I'll try to get some closer pictures of it, but if you click on the picture, you'll get an enlarged view that is easier to see.

Notice at the top left, the Cyclotron. That's where the protons are "harvested", (my word...). The protons are Hydrogen protons which are harvested by splitting molecules of water.

The water molecule (H2O) is split into its component atoms to give 2 hydrogen and 1 oxygen atom. The oxygen is discarded and I'm guessing a couple of them get together to form an oxygen molecule (O2). Where that goes, I'm not sure.

Coming back to the hydrogen, now we have these two hydrogen atoms, each with one proton and one electron. Now its time to split the protons off from their electrons. As I understand it, all of this splitting is done by shooting very high levels of electricity, (235 million volts), at the molecules and atoms. (One of the things I'm not clear on is if that happens inside the cyclotron. I'll find out and correct this if not.) In any case, the atom is split into its one proton and one electron and they 'discard' the electron by simply running it to ground. (Imagine the size of THAT grounding spike!!)

Once the hydrogen protons have been separated, the cyclotron accelerates them to 62% of the speed of light. (Yikes!!) That is the speed required for the protons to travel through human tissue to a depth of 13 to 15 inches. It happens through a series of specialized magnets within the cyclotron. At this point, billions of protons line up and are fired down the line that you see coming out of the cyclotron toward the treatment gantries.

Factoid: The cyclotron weighs appx. 200 metric tons! (a metric ton is appx. 2200 lbs.) All of the equipment was built by IBA or Ion Beam Applications in Belgium and had to be shipped here. Because it is so heavy, the cyclotron had to be welded to the bottom of the ship's hold. If the ship had gotten into rough seas and the cyclotron shifted, it might have capsized the ship! Once it arrived in Jacksonville, the available cranes were not able to lift it from the hold and some kind of super-crane had to be brought in to do the job!

Once it got here, they installed it and then built the building around it. Because it is in Florida, they were not able to put it below ground as is usual. Normally the centers are built 40 feet below ground so that the earth is used as a radiation shield. Instead of that, they had to build this place with concrete walls eighteen and a half feet thick! AND, since the normal aggregate that they use in concrete here is relatively porous, they had to import granite aggregate from up North. Using the more porous aggregate would have allowed radiation leaks!

I mentioned above that they use 235 million volts to harvest the protons. All of this and also the transmission of the protons down the line causes a great deal of heat which must be managed. For that, they have many many water lines that course through the whole mess. Bottom line? They use LOTS of both electricity and water! The bill for each commodity is over $50,000 a month! (and I thought ours was bad!)

The three large circular things you see to the right of the cyclotron are the treatment gantries. The beam is turned and directed down the line by a series of magnets. Since the proton is a positively charged particle, they used positively charged magnets. The two repel each other so by careful placement of the magnets, they are able to direct the protons wherever they want them. (That is horribly oversimplified, but it was about as much as I could understand! LOL!)

Factoid: The gantries were brought in in pieces and assembled right where they sit. Each gantry is over 40 feet in diameter and weighs 110 metric tons! They are so well balanced that a person could turn one with bare hands. They are moved by two 1.5 horsepower electric motors.

So now the proton beam is at the back of the gantry. If you look back at the picture and look at Gantry #1, you see that it is rotated so that the "nozzle" is coming down from the top. (If I were on the table, I'd be looking up at the nozzle.) That monster that runs over the top of the gantry to the nozzle is the path that the beam takes. The thing you see at the very top houses an 8,000 pound bending magnet which finally gets the beam to the right place!

Factoid: The final turn to get the beam into the nozzle is done via an 8,000 pound bending magnet.

Now the beam is at the nozzle and this is where my therapists take control of it. (Up to now, Ion Beam Applications has had it.) By this time I would have been rotated around so that I was lying on the table head-first into the gantry. On the picture, Gantry #3 has been rotated into the treatment position and we would be treating through my right hip on that day.

I have to thank God that there are people out there who are so much smarter than I and who can conceptualize something like this, get it built, and then run it so successfully.

I am utterly in awe.

Typical Treatment

Today is June 25th and treatment #21 is done. Here are some of the pictures that Josh took to show what a typical treatment looks like. He was only allowed to stay in the room until the XRays were about to be taken, but after that not much changes.

This is the front of the Florida Proton Treatment Center. It is on the campus of the Shands/UF Medical Center, but is an independent entity.

When I go into the center above, I have a bar-coded name badge that I have to swipe under a reader of some kind that enters me into the computer and tells everyone that I'm there. (On time or early, of course!!!)

When they are ready, one of the therapists comes to the waiting room and asks if I've finished drinking my water (more later). If so, they bring me here.

On the left you can barely see one of the changing rooms. (Thats where I'm allowed to don the designer gown that I wear for treatment.) On the far right, you can just see the control room where the therapists go to kick off the proton stream and wait until it is finished. The glass doors in the center of the shot are where I go in for my treatments. Just to the right and above are the status indicators. So far I've been able to resist the obvious question, "How many times have people said, "Beam Me Up, Scotty!" ". I'll let you know how that goes...

This is a generic shot of one of the body molds. Each patient has one that is made specifically for him or her. Basically it is a bean bag. We lie down in it and scrunch around, (sorry for all the technical terminology), and then they attach a vacuum machine and evacuate all of the air. The result is a very firm mold. (We used very similar things to immobilize fractures when I was a paramedic.)

The table in this shot is in the treatment position as opposed to the next shot.

Here, my body mold is on the table covered by a sheet before I jump in there. Note that this is prior to the table being moved into the treatment position.

I lie down on the table and my therapists then use the marks on my hips to line me up in the preliminary position for treatment.

I'm now on the table, in the mold, feet facing into the gantry. If you click on the picture to enlarge it, you can see the mark on my hip and the laser lines that they use to get me into the "preliminary position".

Then they push some buttons on their magic box and the table rotates to put me into the gantry where they will do the XRays to line me up for the actual treatment position and then blast away with the protons...

Now the table rotates 180 degrees into the gantry. Right now, I'm about halfway there...

Note the "Nozzle" that I'm about to go under. It has to be in that position so that they can get me in there. Then they will move it to the correct position for whichever hip they are shooting through that day.

Woo Hoo!! Treatment position! Looks like we are treating through my right hip today. The nozzle is in position.

Note the two rectangular box-like things on the back wall of the gantry. Those are the digital XRay panels that will slide out in a second so that they can take pictures of me and my prostate right at the present moment and then adjust the table to bring me into the final treatment position. Their tolerances are 0.2mm!! Close enough for me!

The XRay panels are extended and we are ready to shoot the pictures and then make the final adjustments.

Then the panels will retract and I get my protons for the day.

I get my appointment time for the next day and off I go!

God is good!

June 24th - Halfway There!! Yea!

Today was a pretty good day. I treatment number 20 of 39 so I'm officially half-(oh, the temptation, you know where they're shooting these little protons...) cured. If things continue without any more canceled appointments, I can expect to finish up on July 22nd.

They called me to come in early this morning because things were going well and they were ahead of schedule. Well, they may not call me any more. Broke the table again. Slowed things down a bit. Dumb table just doesn't like me.

Josh got some pictures while he was here. I'll post them in a little while. Need to run them through Photoshop and fix a few things first.

It is about 1700 here, (5PM Landlubbers...), and the afternoon thunderstorm is heading up from the southeast. I hear it coming, so I'll go watch it for a bit.

The People Make Such A Difference

Day 19. The appointment was at 0930 and Josh came with me to see how it works and to take some pictures for me.

The folks here are just SUPER about letting family members come back into the treatment rooms and see what is happening. Great idea! I think it really helps to allay some of their concerns when they can see that everything is absolutely on the bleeding edge of technology and the kids doing the treatments are completely competent.

The director here had a real opportunity when they set this place up. Since it was a brand new and separate facility, he was able to hire everyone from scratch. In my opinion, they did a stupendous job. They found people who are the best at what they do, AND, to a person they all have a wonderful customer-service attitude. I cannot say enough good things about the staff here.

Anne and Josh each came into the treatment room on different days and Loren, one of my therapists, took them aside and showed them the computers, how they used the xrays each day to line me up so precisely with the gold seeds in my prostate, and so forth. These folks are busy and I very much appreciate the way they try to take care of the family as much as the patient.

Josh Is In Town

I took Anne to the airport this morning at about 0500 and then killed time until Josh arrived a bit before 1000. This being Sunday there is no treatment to go to so we had a clear day. We dropped his stuff off at the condo and I showed him around and then we decided to go down to St. Augustine to see the World Golf Hall of Fame.

It's about a 30 minute ride down there, but I managed it in 45 by cruising right past while we were yakking. Don't ask. It's a gift...

I never knew it, but Bill Murray and brother(s?) have a restaurant. Bet you can't guess... Caddyshack! Well it is right beside the Hall of Fame, so we went in and had lunch. Great fun, the servers are 'caddies' and the food was great. If you go, you should really try the onion rings!

The Hall of Fame was fascinating. Tons of little geegaws and memorabilia. They were doing a special presentation on Jack Nicklaus and had lots of his stuff along with videos and on and on. Very worthwhile.

Beach & More Pictures Are Coming

(FYI... Before I start this post, I've figured out how to get the dates right so I reorganized the old ones and added some new stuff. The new stuff may be before some of the stuff you've already seen so if you're interested, scroll down to see what's new.)

It is Friday and I just finished with treatment #18. 21 to go! Things went very well this afternoon. I've developed a couple of "suntan spots". One on each hip, about an inch and a half in diameter. That's one of the things they tell us to expect. It is a result of shooting the radiation through there. Usually they don't get irritated and, so far, mine haven't.

The treatment time today was late afternoon so in the morning I took Anne out to see Jacksonville Beach. It's a very nice community on the Atlantic and we drove around and found a nice hole-in-the-wall place to have some lunch. Fish Tacos!! Walked down to the beach to look around.

One of the main things that has impressed me here is how clean everything is. The beach was spotless. Even when you walk around in downtown JAX, the streets are clean. No litter...

Josh is coming to visit on Sunday when Anne leaves and I'm going to see if he will go into the treatment room with me and get some good pictures. Hope I'll have some to post next week.

Next post, some interesting factoids!!

Birthday Girl & I Broke It!!

Anne's birthday is today. 39! (or so)

I decided to do something really special for her on her birthday so she got to go with me when I went to the Proton Center for my treatment. (What??? What's wrong with that? I'll bet no one took YOU to the Proton Center on your birthday...!)

I left her in the waiting room with a promise that I'd be back in about 30 minutes or so. I went back and changed into a very stylish hospital gown, and I walked into the treatment room. (BTW, when in said gown I've learned not to sit down on the wooden benches in the changing rooms. They are some kinda' COLD!)

This is a picture of a table like the one I lie on. It is rotated into the "gantry" in the treatment position and it has a blue "body mold" sitting on it. The big white thing pointing at it is the "nozzle". The entire gantry rotates around the table to put the nozzle in the proper position for the treatment.

I hopped up on the table and got into my "body mold" and the table promptly broke. They were very kind to reassure me that it had nothing to do with my weight. (So, why do you think they felt that was necessary? Hmm...)

Oh, and didn't I mention the table in an earlier post?

The $1,000,000.00 table?

That I just broke???

Long story short, it turned out to be a software and control-head problem that required replacing a part and rebooting the system. For that, I had to get off the table and we had to start over.

After an hour or so we got the treatment finished. Anne and I then joined the patient orientation tour so that she could hear all about the center and what they do. It was a great tour and I'll detail some of the info in the next post.

Later, Anne and I drove around and I showed her a lot of the city. Jacksonville is a fantastic city and there are just tons of things to do here. In the evening, I took Anne out for the birthday dinner at Ruth's Chris since she had never been. We had a great dinner overlooking the St Johns River. (OK, does that make up for the 2nd paragraph??)

Mama's here!

Anne arrived today. Flew in at about 1800 or so from Dallas.

There is 24 hour concierge service at this condo and when we got back here, James was on duty. Before I introduced her, I told him that I had been out "cruising for chicks" and I found the cutest blonde in the airport.

I think I heard Anne say something about, "Oh, isn't he funny? Not!"

We try...

Porpoises!

My rented condo is right on the St. John's River in Jacksonville. Anne and I love to walk so I've been looking for places we can go when she comes to visit this week. There are lots of good places to walk around here and I tried a new one today. Altogether about 3 miles.

I left at about 0700, before the heat, and walked across the Main Street Bridge to the south side of the river. Then I walked east to the end of the RiverWalk. Along the way, I was looking out at the river and noticed a porpoise cruising slowly by and heading toward the ocean. Didn't know they came up here! Turned out that there were about a dozen of them, adults and children, and they were loafing along. I'd see their backs curl out of the water, a quick blow, and then back under. Over and over. People were coming out of hotels and offices to watch. (Interestingly, they were about 75 feet out from the bank which meant that they were out of the shipping/boat channel. I don't thing that was coincidence...)

Since they were loafing along, I thought I'd step up my pace to stay even with them and be able to watch them longer. Can you say, "Fat Chance!"? They lost me pretty quickly. But beautiful they were!

OMG!! - I. P. Orange!

Yesterday was the first kinda tough day.

Now, understand that "tough day" is relative. There is a lady here who has something called SNUC. Sino-Nasal Undifferentiated Carcinoma. (Think sinuses.) She's getting two proton treatments and one "regular" photon radiation treatment each day and chemo every week. She's in a lot of pain and has facial burns from all the radiation. There are little kids here with various cancers of the brain and spine who have to be put to sleep every day so that they can be treated and other folks who are much worse off than we. So take my little whine with a grain of salt.

In fact, it's not uncommon in our lunch meetings, (support group stuff), for one of us prostate guys to talk about the fact that we are sick, we are being treated for cancer, and for the most part we feel fine. It's almost surreal when we look around at truly sick patients.

That said, there are some things that can happen in our treatment. Lucky me, I've hit one of them. I'll explain the mechanism of how the protons work in another post. For now, they do cause damage to the prostate as they deal with the cancer cells therein. Makes sense, no? Prior to this I guess I never knew that a prostate could hurt. Well, it can. I'm not talking about major pain, it just hurts to pee and feels like one has to pee all the time.

Are We Having Fun Yet?!!

Anyhow, I told the technicians about it and they sent me to the doc. He told me to take Advil, cranberry pills, and AZO, all over the counter stuff. I never knew there was such a thing as cranberry pills! I also never knew that AZO turns urine a bright flaming orange.

SURPRISE!!

Reminds me of when I was a paramedic and we occasionally got exposed to meningitis. We would have to take a drug called Rifampin. That resulted in a VERY bright yellow.

I'm a kaleidoscope! Can't wait to start glowing in the dark.

Amazing Place!

Most of you know that we chose Florida Proton as the best place to help me kill this cancer. Now that I'm here, I could not be happier with the choice!

First, the people. Fantastic! Empathetic, smart, anxious to help. What else can I say?

The facility. It is brand new, about two years, and absolutely cutting edge. They are associated with the University of Florida and I guess that gives them access to additional funds. In any case, they have the best of everything. I hope to get some pictures and statistics that I can share with you in the next couple of days.

To start, here's an interesting fact...

Each day, I go in and lie down on a table on which there is a special mold that they made for me on the first day. It gets me in position. Then they line me up with lasers that have to match the crosses tattooed on each hip. Once I'm exactly in position, the table rotates horizontally 180 degrees so that I'm in position for the treatment. OK, now here's the interesting fact....

That table I mentioned??? It is so precise in it's movements and adjustments, it costs over $1Million!!!

And they have three treatment gantries! Yikes!

True Confession

Well, it's happened. Thought I could resist while I was here, but I guess it was inevitable. Anne's at home and I'm here. (You know how guys are, we can't help ourselves.) Naturally, I've already told Anne and I must say that she took it well.

I have a new girlfriend. Must be the old Navy training. A girl in every port, etc...

Yes, well, it happened at the pool the other day and it was kismet. I was in the pool when she came out of the building. She was in her bikini and was impossible not to notice. Then she saw me looking at her and she couldn't look away either. It had to be a God thing! She paraded around on the pool deck for a while and everyone noticed and watched her. Then she got into the pool and we swam together for about 45 minutes. She waved and whispered, "Hi". When I could catch my breath, I whispered it right back.

She giggled and it was obvious that we were meant for each other. (Star-crossed and all that...) I couldn't understand everything she said because we don't speak the same language. Even better! More exotic!!

Oh, and her mommy said she didn't mind me talking to her.

She's one and just gorgeous!

Welcome!

Thanks for checking in on my new blog. Most of you already know what's happened up to this point so I'll not rehash it all here. Instead I'll try to figure out how to post it in an archive of some kind.

I'll try to update this blog at least once a day. I'll tell you what's happened with the treatments and how I'm feeling. I'll include other things about how difficult life in Jacksonville is, (not!). Hope you find it useful and entertaining...

I'm new at this, so please let me know what you think.