Off the Beam?
BATAVIA, Ill. -- It is a vision of the future that medical scientists have had for more than 40 years:
Inside a space-age hospital room, a team of doctors activate an atomic accelerator. When the whirling protons reach full speed, tbe doctors fire them through a device that looks like a giant Ferris wheel and into the body of a cancer patient. In a few seconds, the proton beam kills cells in a cancerous tumor, leaving nearby healthy cells untouched.
Now, this vision is no longer so far away. Last month, scientists at the Fermi National Accelerator Laboratory here unveiled the first proton beam accelerator built for hospital use. When the machine is ready for operation next year at Loma Linda University Medical Center near Los Angeles, many believe it will prove itself a major breakthrough in the war on cancer.
Others, however, think the proton accelerator is a white elephant. They complain that its untested medical benefits and enormous price make it the ultimate example of medical technology run amok. Some doctors say proton therapy will prove useless in the treatment of most cancers.
Most Expensive Ever
It is unquestionably the most expensive piece of medical equipment ever built. The cost -- $40 million, including the special building needed to house the machine -- dwarfs the cost of the next most expensive medical device: the Positron Emitting Tomography scanner, which shows metabolic activity within the brain and can cost about $5 million.
"It's really stratospheric" for a medicalcal technology, says Peter Ogle, the editor of the trade magazine Diagnostic Imaging. Adds James Slater, the Loma Linda physician directing the project: "It's the most complicated machine ever used in a hospital setting by far." Loma Linda's expectations that the device will eventually treat between 1,000 and 2,000 patients annually "assume the machine stays up and running," Dr. Slater says.
Last year, the project nearly fell victim to federal budget cutters, when the Office of Management and Budget concluded it was a pork barrel project. The agency recommended that $11.5 million in federal funds pledged to the beam be withheld, but Congress ignored the advice.
At this stage, Loma Linda officals say they can't even begin to guess what patients will be charged for treatment on the machine.
Selling Points
Nevertheless, the device does have wide support. Proton therapy for cancer is believed to have a number of advantages over chemotherapy, conventional radiation and surgery.X-rays, for instance, are harder to tame than protons. Not only do X-rays have a tendency to scatter - hitting good tissue around a malignancy - but they also strike, and damage, healthy tissue behind a tumor. In that respect they are like subatomic runaway trains.
Nausea, pain, new cancer and even death are sometimes side effects of conventional radiotherapy. To avoid complications, doctors often lower radiation dosages to spare healthy tissue. But that can allow malignant cells to live and persist in their destructive course.
Protons, however, are more like crack combat troops. The subatomic particles strictly obey doctors' commands. Found in the nuclei of atoms, protons go precisely where doctors want them to and no farther. So while a tumor is being bombarded to death by protons, surrounding. normal tissue isn't.
Protons were first suggested as a potential cancer therapy in 1946 by Robert Rathbun Wilson, who established the Fermi National Accelerator Laboratory. But it wasn't until the 1970's that patients were first exposed to protons in physics labs at Harvard University, the University of California at Berkley, at Fermi and at several institutions abroad.
Moonlighting Machinery
In physics labs cluttered with cable and oscilloscopes, physicists have seen some spectacular results using physics research machines moonlighting to treat cancer patients.
At Harvard, where 174 patients with malignant tumors at the base of the brain have been treated, the therapy has had an 85% cure rate, compared with a 35% cure rate for conventional therapies. (Patients in remission or cancer-free for five years are considered cured.)
Loma Linda, a Seventh Day Adventist institution, had been intrigued with the proton accelerator since the early 1970's. But the hospital didn't do much more than think about it because the needed computing technology and magnetic resonance imaging were either prohibitively expensive or nonexistent. Magnetic resonance imaging, or MRl, is a way of seeing internal organs without radiation. Perfected in the 1980's, it sets up a magnetic field. Different body tissues absorb varying levels of magnetism. Through computer enhancement, an MRI device converts those differences into detailed images of the body.
Then, in 1987, after the study group decided that a hospital accelerator could be built for about $20 million, Loma Linda was the first such facility to come across with the money. Of the about $40 million costs, including $20 million for a new building to house the device, approximately half was put up by the federal government, with the hospital and private donors raising the balance.
By anyone's standards, the Loma Linda device is gargantuan. Patients will never get to see the entire assembly, because walls and floors will be built around it, partly to give it human scale. The accelerator itself willl be shielded by five-to-11-foot walls intended to safeguard against radiation and other hazards, including heat and electricity.
Larger Than Life
The contraption is definitely larger than life, its most notable feature being a trio of three-story-tall gantries resembling giant hamster runs. Each 90-ton gantry will have at its center an enclosed treatment table.
At regular intervals around each gantry are giant magnets that help direct the proton beam. Like the fine-tuning knob on an old TV set, the gantries can be rotated a little to the left or right to move the beam to any angle so that it focuses on the patient's malignancy. The machinery does the moving; the patient just lies there.
Resting within a relatively spacious capsule, 12 feet in diameter, the patient will hear soft music. He will communicate with doctors and technicians by intercom while being observed by them on a TV screen.
So he doesn't fidget out of position, the patient will be set into a customized soft-plastic body cast. The only part of the colossus he will see is the accelerator's treatment nozzle, which resembles the tip of a dental X-ray machine.
Silent Spray
The treatment itself is supposed to take anywhere from seconds to just over a minute, depending on the size and location of a tumor. The spray of protons will occur silently, so the patient won't know what hit him.
Loma Linda expects to bill cancer patients more for the new treatment than it does for conventional radiation therapy but less than it does for surgery. If the hospital were to treat cervical tumors, for example, it would price the procedure at more than $13,000 and less than $23,000.
The Food and Drug Administration has approved proton therapy as a cancer treatment, so patients treated on the Loma Linda device will qualify for reimbursement by Medicare and other insurance. Loma Linda stresses that patients won't be turned away for inability to pay.
Loma Linda is sure there will be enough patient demand for its machine. Harvard treats as many as 12 people a day running full tilt. Patients typically have a two month wait for its machine, says Herman Suit, the chairman of Harvard Medical School's department of radiation medicine. "There's no excess capacity," he says.
Questions of Fees?
The Harvard team selects patients whose tumors stand a good chance of being destroyed by beaming. At Harvard, too, there is no means test. "We've never declined anyone for financial consideration," says Dr. Suit, adding that some patients have been able to raise funds for their treatment through social and church groups.
Loma Linda says it should have the capacity to treat 100 patients a day using its three movable gantry beams and a fourth, stationary beam. "We're prepared to operate 24 hours a day if demand is high enough," says Dr. Slater.
Eventually, the hospital envisions a time when radiation therapy will be synonymous with proton therapy. Dr. Slater predicts the U.S. will have 100 machines eventually, with the cost of a machine falling to $10 million, about half what Loma Linda's prototype is costing.
A San Diego firm, Scientific Applications International Corp., has been hired by Loma Linda to market proton beam accelerators.
"The machines won't be as common as X-ray units, but really major teaching hospitals and medical centers will all have machines like this in five to 10 years," says John Glancy, a senior vice president at the company. "There will be 20 or so machines in the U.S. and a similar number in Europe."
Too Many Machines?
That prospect bothers some cancer specialists who welcome proton machines, but who wince at Mr. Glancy's numbers. They concede that proton beams already have worked wonders in certain tumors, but they say the device is unproved in most cancer cases.
The beam is virtually useless in cancers that have spread beyond the original site. Such metastacized cancers account for more than two-thirds of all malignancies says Y. Joe Kwon, a radiation oncologist in Victorville, Calif.
"There's some usefulness, no doubt about it. But the candidates for proton therapy are limited," says Dr. Kwon. "It won't make a major impact on the cure rate for all cancers. It will make a little dent, but it will cost a lot to make that dent."
Says Thomas DeLaney, a branch chief and senior Investigator at the National Cancer Institute: "The effort should be supported, but I think the number of machines necessary is small. We should have them, just like aircraft carriers, but that doesn't mean every state should have one."
Cost Effective?
Some question whether in a time of austerity, when the Bush administration proposes slashing $5 billion from the Medicare program, even one beam machine should have been constructed.
"I can't understand why the hell they built this ridiculous unit," says Joseph Imperato, a radiation oncologist and assistant professor at the Northwestern University Medical School. "It's a great physics project, but some of the medical claims are lunatic," he says.
The deeper a tumor is in the body, the fewer proven differences there are between what conventional radiation and protons can do, he says. Also, significant side effects from conventional radiation affect no more than five percent of cancer patients, he says. He fears that people suffering from cancer may draw false hope from the Loma Linda machine, a device that, so far, has few demonstrated uses.
Says Dr. Imperato: "If my administrator came to me tomorrow and asked me if he should spend $20 million to get one, I'd say to him, 'You're crazy, out of your mind. It's a waste of money'".