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Technology - Cancer Therapy Facility

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CONSIDER USE OF NAL LINAC, BOOSTER FOR CANCER THERAPY

In 1971, a proposal was submitted to study the use of the NAL linac and booster for cancer therapy. This proposal, with a number of investigators from many leading medical institutions in the Chicago area, as well as NAL participants, was submitted to the National Cancer Institute of the Department of Health, Education, and Welfare in October.

The use of protons for cancer therapy is not new. NAL's director. Dr. Robert R. Wilson, pointed out many of the advantages of using protons as early as 1946 in an article in the journal "Radiology." Research in this field developed slowly due to the lack of time on accelerators of sufficient energy to achieve the required penetration of the protons into deep tissue.

Interest in this use at NAL began in spring, 1971 with a widely quoted paper by Louis Rosen, of the Los Alamos Scientific Laboratory, at the Particle Accelerator Conference in Chicago. Dr. Rosen discussed the application of particle accelerators to other fields than physics research. Professor Lester Skaggs, of the University of Chicago and the Argonne Cancer Hospital, a distinguished scientist in medical physics, was stimulated by this talk to begin discussions with NAL staff members looking toward the use of our accelerator.

An advantage of NAL is that patients could be drawn from the whole Chicago area. The metropolitan-area population of 8 million could be expected to produce 24,000 cancer patients per year, of whom half, or 12,000 will need some kind of radiation therapy. There are seven medical schools in the area, all interested in this possibility for treatment.

Most radiation therapy has been carried out with X-rays or electron beams. Heavy particles like protons offer an advantage over X-rays or electrons in that the radiation dose can be localized much better at the site of a tumor, so that the radiation is concentrated where it is needed and does not inflict as much damage on healthy tissue on the way to the tumor. Protons have been used for cancer therapy with significant success for some time, notably at Berkeley, Harvard, and in Uppsala, Sweden. The NAL linac was busy as an injector for the main accelerator only about one-fourth of the time and could produce an ample proton beam in the remaining three-fourths of the time.

Awschalom, Radiation Physics, Donald E. Young, who directed development of NAL's Linac, and Professor Lester Skaggs, of the University of Chicago, discuss cancer therapy unit proposal during recent meeting at NAL
Awschalom, Radiation Physics, Donald E. Young, who directed development of
NAL's Linac, and Professor Lester Skaggs, of the University of Chicago,
discuss cancer therapy unit proposal during recent meeting at NAL


Photo by Tim Fielding, NAL

There was considerable interest in evaluating the relative effectiveness of protons, heavier ions and pi-mesons for therapy. It was possible that NAL could provide a facility for a pion beam as well as a proton beam through the use of the booster.

Dr. Skaggs sponsored an area-wide meeting in August, 1971 to organize the effort. The chiefs of radiotherapy of each of the seven medical schools responded and all actively supported the project. A symposium was held at the Laboratory on December 4, 1971 jointly sponsored by the American Association of Physicists in Medicine, the Metropolitan Association of Radiation Therapists, and NAL, with over 130 participants discussing their experience in heavy-particle therapy.

There was considerable interest in the possibility of cancer therapy at NAL. The proposal to NCI, which had Professor Skaggs as principal investigator and 15 NAL and area scientists and doctors as participants, asked for funds to carry out a study of the desirability and feasibility of such a project and to establish what equipment and facilities would be needed. A review board from NCI visited NAL in February, 1972.

Among physicians and scientists in the Chicago metropolitan area who have expressed interest in supporting the proposal were: Jaques Ovadia, Ph.D., Director, Medical Physics Section, Dept. of Radiation Therapy, Michael Reese Hospital, Associate Professor of Medical Physics, Dept. of Radiology, University of Chicago; Melvin Greim, M.D., Professor of Radiology, Director Chicago Tumor Institute, University of Chicago; Frank Hendrickson, M.D., Chairman, Dept. of Therapeutic Radiology, Rush Presbyterian-St. Lukes Hospital, Professor, Rush Medical College; Edwin Liebner, M.D., Professor and Acting Chairman, Dept. of Radiology, University of Illinois; William Moss, M.D., Director, Therapeutic Radiology, Chicago Wesley Memorial Hospital, Professor, Northwestern University School of Medicine; James J. Nickson, M.D., Chairman, Dept. of Radiation Therapy, Michael Reese Hospital, Professor of Radiology, Dept. of Radiology, University of Chicago; R. Perez-Tamayo, M.D., Professor of Radiology, Director of Therapeutic Radiology, Dept. of Radiation Therapy, Loyola Stritch School of Medicine; S. Stefani, M.D., Chief of Service, Dept. of Therapeutic Radiology, Hines V.A. Hospital, Professor of Radiology, The Chicago Medical School; Warren Sinclair, Ph.D., Director, Division of Biological and Medical Research, Argonne National Laboratory, Professor of Radio-biology, Dept. of Radiology, University of Chicago.

Source: The Village Crier Vol. 4 No. 1, January 6, 1972

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FIRST BEAM IN CANCER THERAPY FACILITY

Don Young on test of CTF controls
Don Young on test of CTF controls
Miguel Awschalom, Lionel Cohen watch final preparation
Miguel Awschalom, Lionel Cohen watch final preparation

About 2 a.m. on Thursday, July 17, 1975, the Accelerator Division successfully created the first beam of neutrons for the Fermilab Cancer Therapy Facility (CTF).

The success comes close behind the granting of funds on June 12 by the National Cancer Institute for the operation of the Fermilab CTF for the coming year.

The two milestones bring closer to reality the hope that by the beginning of 1976 the Facility can be used to study the effectiveness of neutron irradiation in the control of certain types of cancer.

Many months of determined effort by Fermilab personnel has led to this opportunity to demonstrate the feasibility of using the Fermilab linear accelerator as both an injector in the accelerator system and as a source of radiation for medical research.

Miguel Awschalom and Don Young have directed the physics effort involved in the Fermilab CTF. They have been aided by a number of other staff people who have frequently volunteered their efforts over and above their regular jobs at the Laboratory.

The present arrangement for an adaptation of a portion of the linac gallery is a metamorphosis from several earlier ideas for applications of the linac for medical purposes. The Illinois chapter of the American Cancer Society also contributed $17,300 to the project last February. The NCI grant covers operational funds. Funds to build the facility must be found elsewhere. High energy physics research funds are not used for this purpose.

The Fermilab linac accelerates protons to 200 MeV for injection into the other accelerators, but only .8/second out of every 6-second cycle of the accelerator operation requires the linac injection. The remaining time the linac beam is available for other use. The neutron beam to be used by the CTF is created by using 67 MeV protons from the linac, carrying them to an adjoining room where they bombard a lithium target, creating neutrons which can then be focused to a tumor site. A neutron is an uncharged, subatomic particle with a mass close to the mass of the proton, the type of particle accelerated at Fermilab. One of the chief advantages of fast neutron beam cancer therapy over conventional x-ray therapy is that the neutron beam does not do as much damage to surrounding healthy tissue.

(L-R) Doug Maxwell, Tom Larson, Max Palmer making CTF plans
(L-R) Doug Maxwell, Tom Larson, Max Palmer making CTF plans
Jeff Gannon (L), Russ Winje on CTF controls
Jeff Gannon (L), Russ Winje on CTF controls

In order to extract the 67 MeV protons from the linac, tank #5 of the linac was moved seven inches downstream several months ago to permit extraction devices to be installed. In recent months, as the operation schedule permitted, a hole was drilled through the linac shielding wall and other necessary work completed for the new installation. Shielding blocks for the new CTF were acquired from the former Princeton-Penn Accelerator. Software was written and tested in the linac computer.

For at least the next five months, the properties of the Fermilab neutron beam will be studied from a medical physics point of view. The size and shape of the beam, the projected dosimetry, as well as biological studies using bacteria, tissue cultures, and small mammals, will be carefully evaluated.

A large group of physicians and radiologists from the Chicago area has worked with Fermilab personnel in planning and designing the CTF. Dr. Lionel Cohen, head of radiology at Michael Reese Hospital in Chicago, serves as head of the Fermilab CTF. If initial tests are successful and work with human patients is authorized, the medical profession is expected to refer patients from all over the United States for treatment at Fermilab. The use of fast neutrons for cancer therapy has been tested with encouraging results at several other institutions in other parts of the world. About 1,000 patients a year could be treated at Fermilab in the new facility. It is planned that no patients will be housed or hospitalized here.

"This has been an effort of many people contributing time and effort in addition to their normal laboratory responsibilities," Don Young reports. "These first achievements in this intensive program, which may ultimately play a vital role in saving lives, are results of those efforts. Although more have contributed than can be mentioned here, all of these efforts are greatly appreciated. We should use this example in our future efforts to achieve the long-range goals of Fermilab."

Marlin Palmer surveying beam line
Marlin Palmer surveying beam line
Bob Weber (L), John Larson on last minute vacuum test
Bob Weber (L), John Larson on last minute vacuum test

Source: The Village Crier Vol. 7 No. 30, July 24, 1975

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CANCER THERAPY FACILITY: THE FIRST SIX MONTHS

Anne Mansell, R.N., CTF protocol nurse, welcomes patients for therapy
Anne Mansell, R.N., CTF protocol nurse, welcomes patients for therapy
L-R are F. Hendrickson, S. Ubaldi and Ivan Rosenberg in CTF control room
L-R are F. Hendrickson, S. Ubaldi and Ivan Rosenberg in CTF control room
A. Jones, operations technician, is shown with beam control equipment
A. Jones, operations technician, is shown with beam control equipment

On September 7, 1976, Fermilab's Cancer Therapy Facility (CTF) made history when a volunteer cancer patient received a neutron dose treatment.

Since then, CTF activities have attracted world-wide attention. Press reports in newspapers, Time Magazine and other national media have spread the word of Fermilab's "neutrons against cancer" research. The Village Crier has chronicled CTF's progress; this is an update in a continuing series on the expanding role of the CTF.

Dr. Lionel Cohen, CTF department head and a radiation oncologist (tumor specialist) at Michael Reese Hospital, Chicago, says initial results are encouraging. However, he emphasizes the highly experimental nature of the program.

Of 51 patients referred by medical professionals for possible therapy, 45 have entered the program. To date, 38 patients have been irradiated. Most are Illinois residents, but other states represented are Michigan, Wisconsin, Ohio and Virginia. (One patient commutes weekly by airplane from Ohio.)

Most patients have been 40 to 60 years old, with men outnumbering women 3 to l. A 29-year old man is the youngest patient treated; the oldest, a man 77.

About two dozen patients have completed treatment. Fourteen are currently under treatment from one to three times weekly and three have dropped out of the project. Head and neck cancers account for the largest group of patients treated. Other types were abdomen, pancreas, breast, chest, brain, uterus and tissue.

About half of all patients irradiated receive only neutron therapy. Half were referred for a combination of neutron and conventional photon, X-ray, beam therapy. "It is fair to state," Dr. Cohen said, "that reactions have been relatively mild. No untoward or unexpected acute reactions have been observed in any patient treated so far. It is too early to evaluate the tumor response.

"We feel that these patients represent a sufficient number to complete the pilot studies," Dr. Cohen said, "and propose to follow them carefully for the evaluation of late reactions and tumor responses."

Currently the CTF is using about 60 hours per week of linac beam time. Work involving patient treatment takes 222 hours of this time. The CTF facility will add Saturday treatments to the Monday, Tuesday, Friday schedule, perhaps in May. Expanded therapy hours will increase patient throughput -- averaging about 12 persons daily in 24-minute sessions (10 minutes for exposure, 15 for preparation) -- and will also comply with a four-day treatment week required for participation in national neutron cancer treatment studies.

Most patients are irradiated while sitting in a specially-designed mobile chair that is lowered to the neutron beam line, a floor below the reception area. However, a thigh tumor was treated in the standing position without difficulty. In a colon tumor case, the patient's pelvis was irradiated with the patient lying down on a specially constructed litter attached to the chair base.

The clinical operation is supported by an extensive support program: beam physics; dosimetry and establishing the radiation distribution using a chemical substitute for human tissue. After clinical priorities, the major effort has been to build custom-made collimators--cement and plastic particle gun barrel-type guides that direct and absorb neutrons -- for individual patients.

A third priority is the continuation of radiobiological studies on both microbiological and mammalian systems.

Many users (medical professionals referring patients) have visited and observed their patients. One distinguished visitor last year was physicist David K. Bewley of London's Hammersmith Hospital, where neutron irradiation for cancer has been used since the 1960's. While at Fermilab, Dr. Bewley provided valuable input toward streamlining the CTF operation. The office guest book also records visitors from France, Switzerland (including CERN) and Japan.

In addition to 38 patients treated, CTF's other success story is one of cooperation -- cooperation between physicians, medical physicists, radiation therapy technologists and Fermilab staffers, all with widely diversified specialties.

According to Dr. Frank Hendrickson, CTF deputy head for medical affairs and a radiation oncologist at Rush-Presbyterian St. Luke's Hospital, Chicago, Fermilab offers advantages for potential patients and the advancement of scientific knowledge. Of an estimated 8 million people in the metropolitan area, about 11,000 annually are cancer victims and 1,000 of these may be suitable for research at Fermilab. Typically, after patients are treated at CTF they then return to work, their homes or travel accommodations. Its central location, with auto, train and plane transportation facilities readily accessible make Fermilab convenient to many patients.

Of about 40 referring physicians, about a dozen have volunteered services in the clinic. Volunteers have supervised treatment, examined patients on treatment, noted responses and reactions and dictated clinical notes. "This has been an invaluable aid" Dr. Cohen said, "and made it possible for Dr. Hendrickson and myself to continue the operation at the maximum capacity."

Medical professionals volunteering include: Dr. William Brand and Dr. Stanley Hoover, Northwestern Memorial Hospital, Chicago; Dr. T.C. Chiang, Michael Reese Hospital, Chicago; Dr. Frank Hussey, Jr., Lutheran General Hospital, Chicago; and Dr. Raphael Garces and Dr. Richard Renn, Evanston Hospital.

Non-medical volunteers are: Jordan Finstein, computer department; Duane Voy, radiation physics; Danny Spelbring, Northwestern University graduate student on experiments 305/397; and Allan Halline, a Bucknell University undergraduate who assisted last month.

CTF staff members, in addition to Drs. Cohen and Hendrickson, are: Miguel Awschalom, Ph.D. physicist, deputy department head; Don Young, Ph.D. physicist, associate department head; Ivan Rosenberg, Ph.D. medical physicist; Mrs. JoAnne Mansell, R.N., protocol nurse; Kathy Gehl, administrative assistant; and Alan Jones, operations technologist.

Source: The Village Crier Vol. 9 No. 8, February 24, 1977

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DOCTORS VISIT FERMILAB

Doctors Visit Fermilab
Doctors Visit Fermilab

About 100 DuPage County Medical Society members and guests visited Fermilab last week for a general orientation and tour of the Cancer Treatment Facility. Above left, Fermilab physician Dr. Charles Lang (R) greets (L-R) Dr. Kenneth Hood, Dr. Norbert Leckband, Mrs. Leckband and Mrs. Hood. In right photo, Dr. Frank Hendrickson, CTF deputy head for medical affairs, explains accelerator control room operations.

Source: The Village Crier Vol. 9 No. 12, March 24, 1977

 

CTF CELEBRATES FIRST ANNIVERSARY

CTF Reception Area: attractive and functional
CTF Reception Area: attractive and functional
B. Wyman, technologist, prepares patient for treatment
B. Wyman, technologist, prepares patient for treatment
F.Hendrickson, M.D., and B. Wyman assist patient after treatment
F.Hendrickson, M.D., and B. Wyman assist patient after treatment

Fermilab's Cancer Therapy Facility is one year old this month.

The first volunteer, a tongue cancer victim, was treated Sept. 7, 1976. Since then, a significant number of patients have completed treatment; many pilot studies have been concluded; and a second federal grant for operating expenses has been received.

CTF researchers seek the answer to the question: "Are neutrons better than X-rays in treating some types of cancer?" From first-year results, the answer seems to be a qualified "yes," according to Lionel Cohen, M.D., CTF head and head of the radiation therapy department at Chicago's Michael Reese Hospital. He reports these patient statistics:

  • 120 patients referred by cooperating physicians.
  • 96 patients entered the CTF program.
  • 85 patients completed treatment.
  • 18 patients were considered unsuitable for treatment.
  • 11 patients withdrew before completing treatment.

Most patients are 40 to 60 years old. A 22-year-old man was the youngest patient treated; the oldest, a man 87. Men outnumber women 3 to 1. Because the CTF is an out-patient-only facility, most patients are Chicago area/Illinois residents. However, patients have come from Florida, Indiana, Michigan, Ohio, Virginia and Wisconsin.

During pilot studies, the tumor sites treated included: head and neck; brain; pancreas; bone; abdomen; breast; skin; and chest. The treatment types may be classified into neutrons only; neutron "boost" after standard radiation; and full neutron irradiation after recurrence following conventional treatment.

"Initial observations suggest," Dr. Cohen said, "that the neutron beam as the sole method of treatment was highly effective in controlling tumors."

He added that he was gratified with rapid improvement observed in most irradiated tumors. Treatment reactions have been generally mild; only one patient showed a significant skin reaction which is now healing well.

Patients given a neutron "boost" after conventional radiation have reacted similarly to patients receiving radiation only, Dr. Cohen said. From surgical findings, the neutron boost/X-ray combination seems effective he also noted.

Some CTF staff members pose for a photo between patients. L-R are: K. Gehl, J. Jeurink, I. Rosenberg, D. Spelbring, J. Maxwell, A. Jones, and M. Awschalom. (Not shown: D. Young, J. Ovadia)
Some CTF staff members pose for a photo between patients. L-R are: K. Gehl, J. Jeurink, I. Rosenberg, D. Spelbring, J. Maxwell, A. Jones, and M. Awschalom. (Not shown: D. Young, J. Ovadia)

 

As expected, the results in a group conventionally radiated and then treated with a second full course of neutrons when the tumor reappeared were less encouraging.

Except in selected cases, pilot studies are completed. National protocols -- strict, descriptions for performing specified medical studies--were activated at CTF in June, 1977. National participation means that patient treatment results from Fermilab will be combined with comparable data being compiled at the other national treatment centers: M.D. Anderson Hospital and Tumor Institute, Houston, Tex. and the Naval Research Laboratory, Washington, D.C.

A recent CTF users' meeting featured (L -R): S. Stefani, M.D.; R. Garces, M.D.; W. Brand, M.D.; M. Awschalom; L. Cohen, M.D.; and F. Henderson, M.D.
A recent CTF users' meeting featured (L -R): S. Stefani, M.D.; R. Garces, M.D.; W. Brand, M.D.; M. Awschalom; L. Cohen, M.D.; and F. Henderson, M.D.

 

National protocol participation is coordinated by the Radiation Therapy Oncology Group (RTOG), Philadelphia, Pa., under contract with NCI.

CTF will add Saturday treatments to the Monday-Tuesday-Friday schedule as protocol patients require them. Expanded therapy hours will increase patient processing-from about 12 persons daily to 25-30 persons--and will comply with a four-day treatment week required for participation in national protocols.

From top, in CTF control room are: J. Jeurink, D. Spelbring, I. Rosenberg and A. Jones
From top, in CTF control room are: J. Jeurink,
D. Spelbring, I. Rosenberg and A. Jones

Most patients are irradiated while immobilized in a fixture designed here. The fixture is hydraulically lowered to the neutron beam line, a floor below the reception area. The fixture allows treating patients sitting, standing or, in some cases, lying down.

Dr. Cohen also announced receipt of a three-year $2,186,953 federal grant for operating expenses 1977-80. The award is the second since 1975 from the U.S. Department of Health, Education and Welfare through the National Cancer Institute, one of 11 national health research institutes.

The grant will support: (1) Improved clinical treatment facilities; (2) Physics dosimetric studies; (3) Radiobiologic studies; and (4) Patient treatment. The award came after a March site visit by a 12-person independent review team commissioned by NCI.

"This new support," Dr. Cohen said, "should enable us to expand the clinical operations from three to four days a week. Also, it will allow appointment of necessary additional staff, improvement of treatment facilities and expansion of the radiobiological research participation."

R. Ornitz, M.D. (L) and M. Awschalom at on-site RTOG meeting recently
R. Ornitz, M.D. (L) and M. Awschalom at
on-site RTOG meeting recently

NCI's initial grant in 1975 totaled about $800,000 for operating expenses.

One of CTF's main achievements was treatment of the first patient six months ahead of schedule. In addition to the patients treated, another CTF accomplishment has been sociological: it proved radiotherapists from many medical institutions could cooperate in a single large experiment.

Of about 40 referring physicians, 25 have volunteered services in the clinic. Volunteers have supervised treatment, examined patients, noted responses and dictated clinical notes. "This has been an invaluable aid," Dr. Cohen said, adding that it made possible for him and Dr. Frank Hendrickson, CTF deputy head for medical affairs, to continue the operation at maximum capacity. Users have formed a group that meets irregularly to discuss and develop research protocols.

Fermilab non-medical volunteers included: Jordan Finstein, computer department; Duane Vim, radiation physics; Danny Spelbring, Northwestern University graduate student; Blair Voyvodic, graduate student, McGill University; Gae Beasley, former X-ray technologist; and Allan Haline, Bucknell University undergraduate.

CTF staff members are: Lionel Cohen, M.D., CTF department head and a radiation oncologist; Frank Hendrickson, deputy head for medical affairs; Miguel Awschalom, physicist, deputy department head; Don Young, physicist, associate department head; Ivna Rosenberg, medical physicist; Jacques Ovadia, medical physicist; Jerry Jeurink, radiation therapy technologist; Joanne Mansell, R.N./P.A., protocol nurse; Kathy Gehl, administrative assistant; and Alan Jones, operations technologist.

Source: The Village Crier Vol. 9 No. 37, September 22, 1977

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