Protons 102 (solving the depth and width problem)

Recapping Protons 101, the unique characteristic of proton beams/radiation (over traditional radiation beams) is that protons can go deeper into the body before they (take your pick):

• "Release their energy"
  
• "Do their work"
  
• "Do their damage"
  
  We remember the chart of the Bragg Peak which shows how deep the protons go at a certain level of Mev. Mev is some measure of the energy of the proton beam. I presume that the "energy" of the proton beam is increased by speeding it up. Remember the terms "particle accelerators", "linear accelerators", and "cyclotrons". All of those speed up particles, and, in this case, protons. Imagine a bullet. If it's going 2 miles an hour and hits your skin, it goes nowhere. At the speed of light, it goes through you and keeps on going for a LONG time. So, speed increases energy.
  
  
  The Loma Linda cyclotron will speed up protons, I imagine, to any speed you want. Maybe like putting your foot on the accelerator. I do know that the protons used for my treatment are going 60% of the speed of light (186,000 mps x 60% = 110,000 mps).
  
  Protons are not like bullets, thankfully, so they won't go all the way through my body at that speed. BUT, the prostate is not shaped like a sheet of paper. If the prostate were paper-thin, the protons need only come at a single speed since the depth from the edge of the skin would be uniform (kinda). So, that paper-thin prostate could get treated/bombarded by a one-size-fits-all proton beam. Said another way, imagine that a proton beam travels at 110,000 mps and does it's work at 10 inches. Fabulous! As long as that paperthin prostate is exactly 10" inside your body and, in fact, is paperthin.
  
  Of course, we all know that the prostate is not paperthin. It is roughly shaped like a walnut. Hmmmm. What to do, what to do? We can't treat just a paper-slice of the walnut. How do we get the proton beam to treat the DEPTH of the prostate? Let's think of some possible ways (from a layperson's point of view):
  

1. Move the proton beam gun away from the body each time, i.e. vary the distance from the body before the beam goes in. BUT, remember the Bragg Peak. The protons only start to release their energy when they hit something solid like the body. Maybe if we move the proton beam a few hundred feet away but that is impracticable.


2. Speed up and slow down the cyclotron so that it gives beams with different energies, i.e. 60% the speed of light plus or minus. E.g. 59%, 58%, 61%, 62% the speed of light. I imagine the depth of the beam would vary at different speeds. (Remember, I am a lawyer and am just imagining the possibilities here -- not a physicist or expert at all!) The problem with this approach is that a cyclotron appears to be a clumsy machine (although very intricate). Unlike a gas pedal on a car, it looks like speeding it up and slowing it down, patient by patient, would be much too complex. For example, there are 3 different treatment rooms at Loma Linda treating 4 patients an hour. That's 12 patients an hour (more or less). It is not realistic to speed up and slow the cyclotron down every 5 minutes. There must be another way.


3. Aha! Perhaps a way to do it would be to have the proton pass through something before it gets to the patient's body that can "modulate" the depth of the proton. If it passes through something first (like a bullet going through an orange first), that can change how far inside the body it goes. And, in fact, that is how it is done. The beam coming from the cyclotron is first passed through a "modulator" wheel. Here is a picture of one. The modulator does two things to the beam. The beam is 1 mm wide coming from the cyclotron. It needs to be spread out to the approximate width of the prostate. The beam comes from the cyclotron, hits the spinning modulator, and that increases the diameter of the beam from 1 mm to much larger -- it is now about as wide as a cannon shell. AND, the modulator absorbs some of the beam to different depths. Notice in the picture that the modulator wheel has openings in it. When the wheel spins, some of the beams will pass unimpeded through these openings. These beams will go to their greatest depths. And, also notice that the modulator wheel has different size/depth "steps" on it. See this close up of the modulator wheel here. The steps are different thicknesses. The beams that hit the thinnest of the steps will go almost to the full depth. The beams that hit the thickest steps will go to the least depth. With different steps, we can then elongate the depth at which the beams in total will go.

Here is a graph of the beams that will go to different depths. Thus, the bomb going into that bunker we have talked about will now explode at a number of different depths, not just one, i.e. at 50', 52', 54', 56', etc. And, rather than just one bomb going in at one spot, there will be a cluster of bombs going in all around the area at different places.

Ok, we have the depth and width problem solved. Rather than a single solitary bomb going in that just explodes at a certain depth and only at one point, we have a carpet bombing where the bombs will explode at a number of different depths. But, we now need to be more precise. We don't want to hit those Crown Jewels we talked about before. Yet, we need to make sure we get all the rooms and tunnels. How are we going to shape the beam bombs to just get what we want them to get?

But, enough for now. Stay tuned for Protons 103.

End of Weeks 2 and 3

No side effects at the end of Week 2 nor at the end of Week 3.  9 week treatment (45 total treatments) so am ~1/3 complete.  How time flies.

Week 2 was very smooth.  Treatment, workout, rest, no problems.

Week 3 was typified by machine breakdowns.  Wednesday the machine brokedown at 5:30 am and I had an 8:30 treatment scheduled.  The machine was only fixed at ~4:00 that day and I, along with many other guys, got no treatment that day.  So, add one day to our stay down here.....for now.  Thursday, the machine was broken down (after I got on my bike for a 30 minute ride to get there by 8 am --my treatment time).  The trip was not for naught, however, as I got my workout in.  Still broken after my workout so I went home.  Got a call at 9:30 that night to come down.  As Jane was in San Diego with the car, I hopped on my bike and rode down for treatment, arriving back home about 11:45.  

Protons 101 -- the Bragg Peak

I have learned alot about how this treatment works. In a series of posts, I will try to explain both the theory of proton treatment and how it is applied at Loma Linda for prostate cancer.




We start at the particle level. Atoms. Made up of proton(s), neutrons, and electrons. Protons are the positively charged ones and electrons the negatively charged ones. We used to think that these were the most elementary part of nature, i.e. these were the building blocks for all matter. Now, however, it is believed that quarks,leptons, and gauge bosons are the fundamental particles, i.e. elementary particles not composed of even smaller things.

Traditional radiation relies on photons. These are also elementary particles and photons are used in gamma rays, X-rays, ultraviolet light, visible light, infrared light, microwaves, and radio waves. Photons have no mass -- an important point in comparing them to protons, which have a heavy mass (remember, they are the part of the atom that has the +sign).



Photon rays "release their energy" once they hit the body and continue to the target (breast tumor, brain tumor, prostate tumor). And, after they hit the target, they continue to release their energy on through the body as they exit the other side of the target. Most of the energy is released when the photon first comes in contact with the skin -- before it may reach a target deeper in the body. That is why people get "radiation burn" on the exterior of their body -- like a bad sunburn. That's why people receiving photons get it from a variety of angles on their body -- so that it won't do too much damage on the exterior of the body but enough will get to the target to do its work.

























This is a graph of the normal radiation beam (photon beam) as it releases its energy (does its work). You can see that the great portion is released just when the beam hits the first part of the body -- within 1-5 cm of its hitting the body, that's 1/2 to 2 inches. Good for surface tumors but not as efficient for those deep in the body. And, even for the surface tumors, notice that the beam still has about 25% of its energy at 30 cm -- that's 12 inches. So, much of its energy is being released between 1/2 to 12 inches. Tumors not that deep (I image few are) are going to get a lot of radiation around the tumors in areas that don't need it.

Proton beams have a different characteristic. Here is a graph of the proton beam releasing its energy and where most of that energy gets released. This is called the Bragg Peak after William Bragg, an English physicist who discovered it and won the Nobel Prize for physics in 1915 and specialized in x-ray technology even back then. There are 3 things to notice:

1. The very steep ascent of the proton beam's release of its energy and the very narrow range where it releases most of its energy.
2. The depth at which the proton beam releases its energy -- much deeper in the body than photons.
3. The extremely steep descent of the proton beam after releasing its energy (which means that there is no damage beyond the point at which it releases its energy.

Think of the proton beam as one of the "bunker busting bombs" used in Iraq (that did not explode when they hit the ground but are designed to explode -- release their energy -- at a certain depth in the ground in order to destroy underground bunkers. The proton also goes deep into the body before "exploding" or releasing its energy.

What does this all mean? If, and that is a big IF, you can control where the proton releases its energy, and can shape it to the area you want to release it, there is a very effective tool for treating diseases deep in the body without as much collateral damage when the beam enters the body and with virtually no damage as it exits the body.

From the graph above, however, the proton beam is releasing most of its energy at about 24 cm. What if the tumor is located at some other distance? And of course it will be. If a bunker busting bomb explodes 300 feet underground but the bunker is located at 200 feet or 500 feet, the target will be missed (imagine a bomb that does damage only in a very narrow area, say 5', like protons). How do you adjust the depth at which the proton does its work? And, if you want that bomb to destroy something that is 100' long, how do you increase its 5' working depth to 100' ?

Here's another problem. At Loma Linda, the proton beam enters the treatment room at only about 1 mm in diameter. If your target is the prostate, how do you enlarge that beam to the size of the prostate? The prostate is about the size of a walnut, far more than the 1 mm beam. The goal is to zap the entire prostate so that beam needs to be enlarged.

And, here's the last problem I will address. The prostate is not square. It is irregularly shaped. Imagine a series of tunnels and rooms for that bunker busting bomb. They are irregular and they are at different depths. You don't want to destroy anything other than the rooms and tunnels because nearby are kept the British Crown Jewels -- a priceless heirloom. But, if you don't get all the rooms and tunnels, 100%, then those Jewels will ultimately be destroyed. So, precision is key.

I will address each of these issues in later posts with such names as Proton 102, Proton 103, etc.

And, if any of you reading this have better methods of describing these things, feel free to do that as well as to make corrections.

Nobel Prize Winner in Physics Elected Proton Treatment

Talk about being in good company. Swiss scientist Georges Charpak, who won the Nobel Prize in Physics in 1992, was diagnosed with prostate cancer. He became a Nobel laureate for his work with particle physics. He chose proton treatment. And at Loma Linda.

My numbers/condition prior to treatment

I promised to post my pre-treatment numbers and condition. Here they are with explanations for what they mean.

PSA ("Prostate Specific Antigen"). My number is 3.8 before treatment. It started at 1.2 in 2000 and took 6 years to get to 3.3 when I had a biopsy and the cancerous cells were found. A rising PSA number is indicative of prostate problems, which may be cancer or a prostate infection ("prostatitis") or other possibilities. My PSA rose as high as 4.1. After reading The China Study, I went on a strict vegan diet for 3 months to see if my PSA would go down -- it did, to 3.6. I figured that a vegan diet would keep my PSA low but would not eliminate the cancer nor eliminate the possibility of a spread. Hence, treatment eventually. (I waited >2 years.) BUT, take a look at The China Study. Very, very powerful and convincing stuff. For diabetes, heart problems, breast cancer, prostate cancer, and more. The power of a vegan diet, plus lifestyle changes, was proven in a large study at UCSF by my doctor there, Peter Carroll, and Dean Ornish. Take a look at this article on that study: http://www.newsweek.com/id/141984 . If you are worried about these things for yourself or your children, read The China Study. From a website called "Dad Talk", here is a review written for the Los Angeles Times: http://dadtalk.typepad.com/dadtalk/2006/01/book_review_chi.html

Gleason Score. My number was 3+3 = 6. The Gleason score is taken from the cancerous biopsy samples. A pathologist looks at the cells under a microscope and grades them based on how they look. Remember your high school biology? Living cells may look like odd-shaped balls -- but they have well-defined edges. Well-defined edges is what you want. If the edges/boundaries of cells are broken, that is more likely a cancerous cell. And, the less well-defined they are, the more dangerous the cancer cell is and the more likely it is to travel to distant regions of your body. The Gleason score was established by Dr. Gleason in the 1960's just for prostate cancer. The smaller the number, the better. But, they hardly ever find cancer in scores less than 5 or 6 because of the very, very early nature of that type of cancer. There are also other scales for other types of cancer. Take a look at this website for a fuller description of the Gleason Score: http://encyclopedia.thefreedictionary.com/Gleason+scale .

TNM Score. My TNM is T1c. The TNM scale consists of the following:

• "T" describes the tumor and uses different numbers to explain how large it is.
• "N" stands for nodes and tells whether the cancer has spread to the lymph nodes.
• "M" means metastatic, and tells whether the cancer has spread throughout the body.

I don't have either node or metastatic involvement so I don't have an N or M number.

The "T" score is further broken down as follows:

• Stage T1: Microscopic tumor confined to prostate and undetectable by a digital rectal exam (DRE) or ultrasound
• Stage T1a: Tumor found in 5% or less of prostate tissue sample
• Stage T1b: Tumor found in more than 5% of a prostate tissue sample
• Stage T1c: Tumor is identified by needle biopsy as a follow-up to screening that detected elevated PSA results
• Stage T2: Tumor confined to prostate and can be detected by DRE or ultrasound
• Stage T2a: Tumor involves less than half of one lobe of the prostate, and can usually be discovered during DRE exam
• Stage T2b: Tumor involves more than half of one lobe of the prostate, and can usually be felt during DRE exam
• Stage T2c: Tumor involves both lobes of the prostate and is felt during a DRE exam
• Stage T3: Tumor has spread to surrounding tissues or to the seminal vesicles
• Stage T3a: Tumor has spread to outside of the prostate on only one side Stage T3b: Tumor has spread to outside of the prostate on both sides
• Stage T3c: Tumor has spread to one or both of the seminal tubes
• Stage T4: Tumor is still within the pelvic region but may have spread to organs near the prostate, such as the bladder
• And so on into areas we don't want to go.

My numbers and scores are fairly run of the mill. Gleason 6 is very common for early prostate cancer. 3.

Here is more on prostate cancer scaling and grading: http://www.henryford.com/body.cfm?id=39165

"Morbidity" (side effects) after 1 week

Today marked my 7th treatment. We go 5 days a week and have the weekends off.

Everybody always wants to know about "morbidity", aka side effects, during treatment. The reported side effects have been only the following, none of which I have yet experienced:

• Diarrhea
• Burning sensation while urinating
• "Sunburn" on hips where protons go in.
• Fatigue

I am happy to report none of those have happened to me. Hoping the exercise will keep the fatigue away, which I understand is the most common issue.

Exercise and Protons -- No sympathy necessary here

Today marked my 4th treatment. Jane and I get a gym membership to the Loma Linda gym (very extensive) as part of the deal.



I have been riding my bike to treatment which is a 30 minute ride there and about 35 minutes back (about a 500' elevation difference). Today should be a typical day for the future:

• Hop on the bike and ride to the hospital


• Park the bike and go down to the treatment room (a bit sweaty since it's about 90 degrees here now)


• Treatment


• Go to the gym and I'm starting at the low end of my usual workout (12 minutes on stairmaster -- working up 2 minutes every day to 20 minutes max; 1.25 miles on the treadmill -- working up .25 miles/day to, say, 3 miles, maybe more; stretches, free weights, and abs) -- about 1.5 hours total. I may even get to double sets on the weights as they are increased.


• Get the bike from the gym rack, and bike home.

All told, about 2.5 hours/day of exercise. I've been looking forward to this period to get in shape --again. I can't lose too much weight because I won't fit snugly in the pod. But, we'll see how it goes.

I also brought my tennis racket and they have an open tennis group that plays every Tues and Thurs morning. I haven't played in about 8 years but think my back may not protest too much.

As you can see, sympathy cards are not necessary. As one of my children said, "Dad, leave it to you to turn cancer into a vacation."

Summary of A Sample Treatment (Day 2) - movies and photos

Day 2. Less anxiety than the prior day. Here I'll post movies and photos of the experience with an attempt to explain things. This will be a rather extensive post.














This first picture is of the "gantry room". This is where I go to lie down in my pod and the radiation is administered. My head will be in the foreground and my feet towards that light. It would seem that the rays are directed from that light but, no, they come from the side -- directly pointed at either my right hip or my left hip. The days are alternated. The first day, I got zapped from my right side and today from the left. Most types of radiation are "fixed beam" where the person is rotated and the beam remains stationery. Here, I am placed at a certain spot but the beam equipment itself is rotated -- either 180 degrees to my right or to my left. I'll later post a video clip of that rotation -- the entire circular area in which I am placed rotates around my body.






But, first, here are some video clips of the display they



have of the entire cyclotron machine which creates, accelerates, and distributes the proton rays to the 3 "gantries" or treatment rooms.






Here is a video clip as I first enter the treatment room, known as "Gantry 3". These folks in this video were on the Today show and NBC news when George Lewis, an NBC reporter, went through this treatment. I also heard a story, to be confirmed later, that one of the female



technicians, ended up marrying one of the patients. It was not "Olivia", who is shown in this clip . Whatever the case, that technician got to know her future husband from the bottom up.












Here I am with the "picture de maison" just before the treatment starts. On my left is the equipment that will deliver the proton rays to my left hip. Stay tuned, I plan to post later a video clip of when everybody leaves the room (just like with xrays) and I am zapped. It's anticlimactic. I will also later post a detailed description of my understanding of how the equipment works.













Molds are made to "conform" the rays to the size and shape of my prostate. Those molds channel the rays to just the prostate area. I don't have a good picture of the molds yet (one is called the "aperture" and the other the "bolus" -- more later on these) but they are kept in these containers which slide into the "proton gun". More on this later as I learn more how it works.

This blue apparently waxy thing ("bolus") is used to vary the depth of how far the protons go into my body. I will post more on this later.

Now, I'm going to show you a picture of the balloon soon. You don't have to look but it's really no big deal. Remember? It is inserted in my arse and is inflated with water in order to provide some degree of separation between my prostate and my rectum in order to avoid the proton rays from striking my rectum, or at least giving some breathing room for the treatment. But

first, here is another picture of the equipment that is the last step just before the protons are beamed into me.

Ok, here it is further down, close your eyes -- the balloon. If you don't want to know, fast forward through this next part. This is for future proton patients who want to know what it is really like and what the details of the ballon are. Some folks have a phobia for this and knowledge is power as well as comfort. I also plan to have a future post with more details about this part of the operation as well as the other parts. This post is just a summary of a treatment.

Really, this guy is not Dr. Kevorkian although he looks awfully sinister in this picture. He actually looks like a high school kid who used to work for me who is now a lawyer -- I know, I know.....just desserts. (I am a lawyer.)

Right after I took this picture, I got slimed. Really. The slime dropped right on top of me. You can see which part goes up my arse. The slimy part. You can see the "syringe" that contains about 1/2 cup (120 mL) of water (tap water) that goes into the balloon. Once up my arse, the syringe pushes the water in to enlarge my rectum to keep the protons away from parts that they, and I, don't want them to be. The tube is clamped off with the clamp you see to keep the water from being pushed out of my over-anxious rectum. The balloon, tube, and clamp (I presume -- details to come later) sit underneath me during the treatment and then is all removed after treatment. It is really not bad, as I said earlier, it is no more discomforting than having your teeth cleaned. And for those of you proton patients who have had DRE's and/or biopsies, trust me, it is much better than any of those.

Ok, the rest of you can open your eyes now.

And finally, when I can get it uploaded, I will have a video of when I was receiving the proton rays themselves. It is also quite boring but you can listen to the sounds. Only hear a whirring sound (the "modulater" turning) and then a series of beeps. It is the series of beeps that indicates when I am receiving the proton rays. We'll get into these details in later posts.

First Treatment

Today was the big day -- first treatment. Loma Linda gives the primo time slots to new patients -- 9-11 am. We don't have to sweat it all day that way.

We arrived at the reception area and did a bit of some preliminaries and they were ready for me early. I barely had time to drink my 2 cups of water.

Into the "gantry room" and climb into my pod. Balloon up the arse and wait. The pod in the gantry reminded me of Hans Solo's starship just before it went into hyperspace. Very futuristic.

Future Posts -- What's Coming.......

We have just arrived for the treatment. To bring some order to this blog, here is what I plan to post in the future:

• My experiences on a day to day basis as I go through this treatment
  






• What treatment and prep is like at Loma Linda -- complete with pictures -- above is a sample to whet your appetite -- the "pod room". Booga, booga, booga...Invasion of the Body Snatchers complete with names.

• Why I chose proton therapy treatment ("why proton therapy....?")
  
  
• The different types of treatment ("so many choices...")



• My particular medical situation ("PSA level, Gleason score....")
  
• How I was introduced to proton therapy ("how I learned of this treatment....")
  
• Our living situation in Loma Linda ("home away from home....") -- complete with pictures!
  
• The surrounding area ("what to do in Loma Linda for Northern California snobs...")
  
• Whatever else comes up
  

You can receive an email every time I post a new entry should you so desire. Just follow the "Follow this Blog" instructions. It may require you to get a gmail account.

And I invite your comments

So Many Choices... Summary of Protons v. Surgery v. Seeds

What to do, what to do? So many choices, so many options. Surgery? Do nothing? Radiation?


If surgery, what type? Traditional radical prostatecomy (cut the whole thing out with a surgeon's skilled hand) or robotic prostatecomy (same surgery but using a tiny robot that is controlled outside the body)?



"Do nothing" is called by various names -- "watchful waiting", or, more euphamistically, "active surveillance".



Radiation comes in many different varieties. The purpose of radiation, like surgery, is to destroy your entire prostate. Early prostate cancer stays in your prostate (almost always) but noone knows where it is - sorry, baby, that entire prostate has gotta go. Unless you want to run a greater risk of a recurrence.

What flavor of radiation beam do you want? The traditional photons or protons. Photons are what an xray machine makes and is the traditional type of radiation therapy. For protons, remember your high school physics class. The atom is made from protons, neutrons and electrons. For proton therapy, the protons need to be separated from the rest of the atom and accelerated to such a speed that they can enter the body.



How do you wanta get your radiation? From the outside or the inside? You can only get it from the inside with "seeds" aka brachytherapy. These are tiny radiactive seeds that are surgically implanted in your prostate and are designed to destroy your prostate over time as they release radiation. How they get all your prostate without destroying other things is always a question. The skill of the doc inserting them in your prostate is obviously a key -- gotta get them in the right place so they won't move later on.



Radiation from outside the body comes in different forms. The usual problem with radiation therapy is that it's like trying to use dynamite to remove the curtain wall between your kitchen and the family room -- it tends to destroy things like the plumbing and electrical wiring in your bedroom at the same time as that wall you want gone. The trick with most radiation is to have it just destroy the curtain wall rather than parts of the rest of the room. Proton beam treatment comes from outside in. So do all types of photon radiation. There are a multitude of types of external photon radiation. Each designed to limit the "collateral damage". They go by a variety of different names, with an alphabet soup shorthand names. Here are a few:

• EBRT ("External Beam Radiation Therapy") -- this is just a general name for external radiation therapy.
• IMRT ("Intensity Modulated Radiation Therapy") -- think about a stick of dynamite that can concentrate its explosive charge where it is most needed and, at the edge of the wall, has a much smaller impact
• 3D-CRT ("3 Dimensional Conformal Radiation Therapy") -- you must be getting the picture by now, this is a way to view the prostate precisely ("3D") and to "conform" the beam to the shape of the prostate so as to not have it damage surrounding areas.

I have not explored all the radiation therapies...for reasons I will explain later.

I will explain later why I chose proton therapy.