David Raubach: I just want to thank everybody for joining us on today’s episode of the Cancer Project podcast. We’re really privileged to have Nick Schroeder here with us. Nick is a legend in the proton therapy space. Um he’s been working with protons and accelerators for multiple decades now. We’re going to hear all about his life and stories and things that he’s worked on and the impact that he’s had on the proton therapy industry. So Nick, thank you for joining us. Niek Schreuder: Thank you David. Thank you for having me. It’s a it’s a joy to uh meet up again and uh discuss uh you know the history and hopefully also touch on the future I guess. David Raubach: Yeah.

David Raubach: Um so to get started why don’t you just tell us a little bit about your background. Uh you’re from South Africa just growing up in South Africa. I think uh most of us don’t have the same upbringing that you had. Niek Schreuder: Yeah I I grew up in South Africa. I moved to United States in 2001. Uh many reasons but the main reason why I moved here was to really be in an environment where I can uh advance proton therapy here. So we we started doing proton therapy in Cape Town in 1993 and that was on a homemade system. Uh you know what I mean with homemade? It was not purchased anything was purchased from anybody.

Niek Schreuder: We built everything ourselves. I built the ionization chambers for the proton beam line together with Dan Jones and many other folks. we added an accelerator and uh yet that gave me a tremendous advantage on top of what modern today’s medical physicists have because you really can’t build anything yourself anymore. So of course we were not at that day under the you know the regulatory FDA. We just had to prove to oursel it’s safe. We we did have the state coming in to review this stuff but anyhow we treated patients with extremely advanced system and uh but then of course it was uh when the when the government changed and rightfully so the political arena changed

Niek Schreuder: and then you know first world medicine had to um you know not was really not a place for first world medicine in that time of and so I thought uh you know I’ll come to United States where they recruited me into Indiana university which had a similar accelerator and uh that system shut down a couple years later maybe about I moved in 2001. I think they carried on till in 2010 15 and something like that but anyhow I I came to United States to see can I be in an environment where I can really um advance and and get protons to a level where more patients can benefit from it. Um so that’s it. There’s

Niek Schreuder: much more to say about that but uh that was a big benefit that I could homemade work on a homemade system. David Raubach: Right. So in South Africa like how did you end up at the proton facility in South Africa? What’s your what what is your background from an education standpoint? Niek Schreuder: Yeah. So I did a bachelor’s degree in physics and uh right at that time and a little bit of history everybody in in South Africa would love to work in Cape Town and was just that time that they installed the nuclear power plant there the first uh nuclear power station I think in the southern hemisphere was built there in Cape Town. So I thought

Niek Schreuder: if I go into radiation physics had all to do with radiation then I can get a job back at the at the nuclear power station in Cape Town. And in fact I did get my job there. They did offer me a job at the same time that the hospital said come back to medical physics. So I actually started instead of making good money at the at the nuclear power station I went into residency and did my medical physics residency and it was also just that same time that the medical program started at the national accelerator center where we had the the proton accelerator. So we actually started treating with neutrons fast neutrons. David Raubach: Okay.

David Raubach: And then we developed our proton uh machine after that. So for those of the listeners that are not familiar with the difference between neutrons and protons, I mean obviously they’re both subatomic particles inside of an atom, but what’s different about the treatment with neutrons versus protons? Niek Schreuder: Yeah. So neutron does not have any charge, you know, so it’s not a charged particle and and interact pretty much the the the dose distribution is very very similar to an X-ray which is also not a charged particle. So if you go to charged particles then you have the the benefit of of the continuous slowing down approximation where the pro particles will eventually run out of energy and

Niek Schreuder: deposit a lot of energy towards the end of the track the so-called brack peak but uh charged particles only charged particles show the brack peak but if it doesn’t have a charge then it’s also called indirectly ionizing so the neutron first have to knock out a proton and the proton deposit energy David Raubach: and x-ray first need to knock out an electron and electron transfers the energy. Niek Schreuder: Right. David Raubach: Okay. So then uh when you were doing your medical physics residency, did you know that you would be working with particle therapy or were you thinking that you might end up working with I guess at the time. So this is the describe I guess describe radiation oncology

David Raubach: in the early 90s. Niek Schreuder: Yeah, it’s it’s very interesting. David Raubach: I wasn’t there. And so in um that was that was South Africa when I first stepped foot into a um radiation therapy center the the hallways were lined with people uh that is getting paliative radiation. So the the cure rate was very very uh you know low primarily because of uh the lack of diagnostic imaging and early detection right. The main change that made that moved the dial in terms of cancer cure was earlier detection, better diagnostic procedures that then also went um hand inhand with better ways of delivering the beam. So we trained uh in in South Africa we trained in both health

Niek Schreuder: physics and in medical physics and so I was exposed to both components but we did like one day a week of our graduate undergraduate program was was in the hospital where I where I was trained in medical physics and then also in health physics at the nuclear power station. So I I trained at the Tigerberg hospital. There was two main hospitals in there still two main hospitals in Cape Town and both hospitals were involved in the medical project at the national accelerator center. So when I moved in there uh to do my residency my professor said you know I want you to also be involved in the in the project at the accelerator center

Niek Schreuder: and so eventually I moved full-time to the accelerator center was actually paid by the national research foundation. uh so I moved away from the government hospital into a um semi-government system where we were doing a lot of research isotope production nuclear physics research and so uh with on the particle therapy side I mean this is the early 90s I guess at the time in 93 um I think the only kind of uh what I would describe as modern proton therapy center in the sense that it’s dedicated to treating patients all day long was at lominda or were David Raubach: Were there other that was the only one in the US were there other ones around the country

David Raubach: or around the world? Niek Schreuder: It’s actually the Harvard Cyclone Lab was still Harvard Cyclone Lab was the pioneers and so they started doing proton therapy I think in the 60s. David Raubach: Um and then Luminda started treating in 1990. I visited Luminda around about that time. My first trip to United States was in 1993 was just after we started treating patients and at that time Harvard Cyclone lab Niek Schreuder: was kind of the best uh was most u treated the most patients because that time is just when Luminda started of course Linda then immediately was the world’s first hospital-based center in fact David Raubach: there’s a good argument to make that our center in Cape Town was actually

Niek Schreuder: the world’s first hospital-based center you know because they had a hospital okay David Raubach: attached to it for particle therapy for both neutrons and protons Niek Schreuder: Um but uh so we were pretty much the third third best equipped and best run facility in the world at that time in terms of producing patients and treating patients with particles neutrons and protons. David Raubach: Oh that’s fascinating. And so what types of cancers were you treating in the early 90s or the mid90s? Niek Schreuder: Well for the for the neutrons was primarily um salivory gland targets is still the for some reason work very well with neutrons. One thing I I have to say the nutrients is very it’s called highle. So

Niek Schreuder: it has a very strong destructive effect on the cells. But of course you also we have to be very very careful about the healthy tissue. And on the proton side we only had the beam two days a week. So we could only do radio surgery. So we only treated intraranial cases all radio surgery cases in the brain very close to the basically pituitary gland tumors AVMs uh non-malignant AVMs non-malignant acoustic nuromomas but all in the brain and we all treated them upright we all treat them seated because we do therapy okay David Raubach: we had a gantry for the Niek Schreuder: yeah and we’re gonna c we’re gonna circle back to that so the upright treatment so

David Raubach: um okay so you’re you’re doing the oh the this is another question I had uh about just kind of the setup in South Africa or just I guess particle therapy in the ’90s. What was the treatment planning system like? Like how long did it take? What I mean was it were there dedicated treatment planning systems or was it kind of a homegrown system? Niek Schreuder: Yeah. Yeah. So I mean we started with a very we started actually by shooting the beam through we didn’t have the ability to u to do and computers were very very slow. Um it’s more or less that time 9395 that time Michael goin started developing the three 3D treatment planning systems

Niek Schreuder: but that was our biggest problem. We our first probably about 100 patients we couldn’t use the bra peak we just let the beam run all the way through but also a very sharp beam and that is actually coming back into the industry to not use the bra peak if you want a very sharp beam. So that’s that’s coming back to the to the past again. Um but the first treatment planning system we used uh did in collaboration with the people at the German research in DKZ. Uh they they built 3D visualization software and there was another group here in United States that pro provided 3D uh software. You know, again, I I took some code

Niek Schreuder: from another colleague was all in scientific collaborations and I pretty much developed the first uh um code to do the 3D calculations and then another colleague of mine. He’s still at the lab there. Um the came and he developed really sophisticated software. We also had Terovski Alexander Terovski from PSI. He was a Russian traveling scientist and he spent some time with us. He did Monticardo. We did Monte Carlo calculations in 1998 909. David Raubach: Wow. Niek Schreuder: Uh very very sophisticated stuff. David Raubach: Describe Monte Carlo. Niek Schreuder: So Monte Carlo what it to the to the lay person. David Raubach: So Monte Carlo physicist all on probabilities. You know you know what is the probability of a certain reaction

Niek Schreuder: coming in and you use a random number generators to say what is the probability and you generate an event and you just track the particles. uh per that event. So it’s really a a fundamental calculation based on uh the randomness of a certain event happening and then and you just simulate treatment and of course if you then simulate millions and millions of protons coming in each proton is tracked on its own then you actually can resemble the the real dose. Compare that with an analytical calculation which is much much harder to correct for everything that happens. David Raubach: Right. Well, and that so just a little bit of a segue here. So maybe describe um and again

David Raubach: uh for me as a non-medical physicist, what’s actually happening with the proton when it goes into the body? Because that’s a question that we get asked pretty frequently by patients is well, you’re telling me you’re shooting protons into the body, but what’s actually literally happening with those protons? What are the what could happen? Niek Schreuder: Right? So it’s actually uh it might be it might sound interesting but proton therapy or the proton interaction in the patient body is by far the easiest of all radiation therapy beams we use right so and I always uh explain it at the end of a football match you know so if a proton comes in so first of all where

Niek Schreuder: do you get the protons from so you just start with hydrogen gas and you put in a plasma and that means the electrons and the protons is becomes freely associated and you just pull pull them apart. And so you basically strip the electron off the hydrogen atom and now you have a proton because remember hydrogen is the first element on the periodic table. One proton, one electron. You strip the electron away, you got a proton, accelerated, but now the proton comes in and fly into the medium. And what’s in the medium is primarily electrons flying around, right? And you got the nucleus with protons and neutrons and stuff in the nucleus and electrons flying around.

Niek Schreuder: But the electron is negatively charged and the proton is positively charged and the two will attract each other. So it’s electromagnetic force between the electron and the proton. So the proton comes into the patient body at a very high speed and and travels so fast we basically shoot it in about twothirds the speed of light. It travels so fast and doesn’t see much of that electron. But then it sees the next electron, the next electron. Every time it interacts with electron, it loses a little bit of energy, right? And then of course the protons can also see the positive charge of another nucleus and be deflected. And in the process of deflecting it, it loses

Niek Schreuder: energy. But the primary energy loss, especially if it comes to the lower energy, is by the attraction of the electrons. And the more electrons attract, the slower it goes. And the slower it goes, the more time it spends in the in the vicinity of electrons and the more energy it loses. So eventually continuously lose energy till it gets so slow that it cannot overcome the electromagnetic force between the electro and it just combines with the electron and becomes hydrogen again. But in that process, David Raubach: it deposit a lot of energy in the medium at the cellular level. And so when it deposits that energy, it’s damaging DNA or what’s I guess there’s some type of

David Raubach: it’s it’s causing cell death or causing damage to cancer cells. Niek Schreuder: Right? So now I have to be careful not to step on the biologist and the radiation biologist toes. But there’s basically two pathways. Uh a lot of energy deposit in the cell can cause DNA damage, but it can also generate free radicals which is a chemical uh cause chemical instability in the cell. and the cell dies as a result of the chemical the free radicals or direct DNA damage right and so if you start increasing the amount of energy deposited per unit distance or per per travel then this is called the linear energy transfer is if that goes up the biological effectiveness goes

Niek Schreuder: up so if I start using we start using particles that’s heavier than the proton like helium or lithium or carbon now you start seeing a much higher ionization density which then and much more likely cause the DNA damage and so-called higher le means higher RBE but RBE radiation biological effect is a defend depends on many other parameters but in principle the protons has a slightly higher significantly higher le towards the end of the range and uh that’s what then that’s what we really want to use in the tumor to see can we have a high energy deposition rate in the target cells to cause more cell damage David Raubach: So I I have an analogy that

David Raubach: I use and you can tell me if this is completely off base. So when I’m trying to explain this impact with smaller particles like protons or a bigger uh particle like a helium or carbon, I’ve described it as throwing differentiz bowling balls down towards bowling pins or maybe even the difference between rolling a tennis ball versus a softball versus a smaller bowling ball versus a bigger bowling ball. Niek Schreuder: Right? And what I say is is that it’s a little bit because you might say, “Well, always throw the bigger bowling ball.” But then I would ask the person, the patient, I would say, “Well, but what if it’s what if it’s a 25 pound bowling ball?

David Raubach: You might not be able to roll that.” Or it might take so much energy to roll that that you’re not able to do that. And so what actually is more practical is to roll a whole bunch of softballs or a whole bunch of smaller bowling balls versus one bigger bowling ball. And that kind of translates to well yeah it’s great if you want to use carbon it’s a it’s a bigger particle but then you need a bigger accelerator and you need bigger magnets and you need more electricity and you need bigger gantries and all of that comes at a cost. So kind of the perfect balance in terms of just the practicality of accelerating a

David Raubach: particle is a proton Niek Schreuder: because you get the benefit of it having a charge and having a mass but it’s not so big that you need these enormous particle accelerators that maybe are not practically or practical to install. David Raubach: Yeah, that’s correct. I mean the bigger the ball the more damage and and and and if that particle comes traveling into the medium the bigger it is the less probability is that it will be deflected by the nucleus. So a heavy particle goes in and actually splits the nucleus. The proton comes in and only splits it at a very high energy. Niek Schreuder: So as soon as you get lower energy the proton just deflects away from

Niek Schreuder: the positive charge because it’s it’s just it’s much smaller than the nucleus. Right? So but if a carbonion comes in it’s quite equal size then you know for example nitrogen and oxygen and so they have head-on collisions and then cause nuclear fragmentation and which is then the thing that causes this extreme high rate of energy transfer over per distance. David Raubach: Okay you’re right I mean the the the lower le of course the fact that it doesn’t have the nuclear interaction means it also deflects more so the beam broadens much more as it goes into the medium. So if you have a a smaller particle you have a more broadening of the beam and in fact

Niek Schreuder: the pinumbra and the definition of the beam deteriorates while a carbon beam remains extremely sharp and and very sharp into the patient’s body. But now on the other hand the nuclear fragmentation has a bit of a nuclear fragmentation tail which is not so good for stuff on the other side of the tumor. So David Raubach: there’s always pros and cons. Niek Schreuder: Yeah. Just with every treat with every treatment there’s a pro and a con. David Raubach: Right. Niek Schreuder: Right. But it’s it’s at least extremely well understood today. You know I I do do believe that the cost is is ultimately the big problem. Right. In terms of these massive accelerators to accelerate the particles. Um so I I

Niek Schreuder: do believe protons is is really a sweet spot but people are starting leaning more towards maybe helium could be the particle of the future. David Raubach: And helium is only four times heavier than the proton. Niek Schreuder: Okay. David Raubach: Well, you heard it here first. Helium is the future. So, uh, let’s go. So, back to your story, your history. So, you end up at Indiana. Um, and then, and so did you get recruited to come there or you just knew that you wanted to go to the United States? And so, you said, well, there’s only a couple of options for particle therapy facilities in the United States like how how did you end up specifically at IU?

Niek Schreuder: Right. So the accelerator the cyclron that we had in South Africa was actually was actually the second version of the cyclron that was developed by the physicist at Indiana University. David Raubach: Right. Okay. Niek Schreuder: So when the South Africans built was tasked by the government to build an accelerator the best accelerator out there to model after was just started working producing beam at Indiana University. So there was a very strong collaboration between the scientists in South Africa and the folks in Indiana University. So we just had this tremendous relationship. And then Indiana University folks did treat a patient u they did some macular degeneration treatments but they did treat a patient uh also in about 1993

Niek Schreuder: also on a on a homemade system. That was again way before uh it was in a national lab setting. And so I visited them the first time in 1993 just to you know share ideas and stuff like that. And then in 97 they said you know when Indiana University lost NSF funding for that accelerator Dr. John Cameron said well we can use this accelerator through medical work right and uh we were continuing to talk and they said Nick if you ever want to come to United States you know let’s let’s work together because I just was involved in building the system in in Cape Town. So they recruited me. It took four years uh took

Niek Schreuder: four years between the first discussion primarily because of them getting the funding for the project, right? And so by the end of 2000, David Raubach: they received the funding and then we started having discussions and I visited November 2000 and moved in February 2001. Niek Schreuder: Okay. And so you moved there in 2001 and they’re treating patients at that point? No, no, it was just they just start stripping uh they just start stripping the accelerator down, David Raubach: remove all the experimental experimental vaults, start putting the beam lines. We treated the first patient I think it was in April 2004. Um so it took about two 3 years more to treat the first patient. Actually what was the

Niek Schreuder: problem there is we would have treated much earlier but we didn’t realize we actually at that point realized we have to get FDA approval whether you sell it or not David Raubach: whether you whether you build a device for commercial interstate commerce that did not uh play a role uh the FDA made a rule that anybody you want to treat with protons must get FDA approval doesn’t matter if you want to sell it or not so we had to scramble backwards then and to get FDA approval in fact the first patient we treated under an investig ative device exemption uh in the fixed beam room. David Raubach: Do you remember what you treated? What was that first

David Raubach: patient? Niek Schreuder: Oh, absolutely. It was a parotic gland uh um para gland uh tumor of a young woman that needed wanted to have proton therapy for the cosmetic uh results. And with just with a fixed beam room, we all huddled up. We we strapped her in a box and then we treated one beam as an lateral beam and the other one as the anterior beam. So we rotated the patient through 90° between the two beams. Uh you know I have to give David Raubach: you rotated the box. Niek Schreuder: We rotated the entire patient and in the box David Raubach: and uh and had a match line because we only had a fixed beam room but the the

Niek Schreuder: team there was Dr. Alan Thornton which I still uh you know get need to get a lot of credit and of course Ed and Mary Beth Dicki and Averil that I brought from South Africa with me. So uh we had a very experienced team to do it and have done this kind of stuff before and so we treated the first patient and uh yeah and we also develop a patient positioner a chair attached to robotic arm to treat patient in a seated position there as well. David Raubach: Okay. And so, uh, you’re there and then what other types of cancers did you end up treating? I mean, were you treating I mean, I know today we

David Raubach: can treat pretty much any solid tumor with protons, but what were what were you treating there in the early 2000s? Niek Schreuder: So, this this was all passive scatter tumors, right? So, you needed to use an aperture and a compensator uh, which really forced you to very solid tumors uh, small small tumors targets. Um so again you had to wrap an aperture around the tumor and you had to be able to make a compensator. Uh a lot of them were just uh intercraanial stuff. Um now we started in the fixed beam room while we were developing two more gantry systems and the gantries only came online I think in 2006. David Raubach: So it was a good

David Raubach: two and a half years we treated in the fixed beam room. And of course there was there was prostates um all kind of pretty much maybe only lowrisk prostates because the iris prostate was a very difficult treatment to treat in that uh um fixed beam room. Niek Schreuder: Right. David Raubach: And who built the gantry? Niek Schreuder: Well, we actually uh you know I sold many gantries to a company in 1997. There was uh I I I forgot exactly what the initiative was but I built a bunch of gantries that was that was just sitting on the shelf. So, we actually just bought the Gantry mechanism from IBA, but we put in the Leo uh the the the Indiana

Niek Schreuder: University beam lines and the nozzle and beam delivery nozzle. And one of the reasons they recruited me because I was at that point David Raubach: fanatically involved in developing a robotic positioner. So, I developed a robotic positioner Niek Schreuder: together with Joe Kun at the Indiana University. And uh we we basically use a commercially available robot that is used to weld cars together in manufacturers and convert it into medical device. David Raubach: Yeah. I I mean I go downstairs and I look at the gantry that we have here at the Oklahoma Proton Center and it’s 36 feet tall. It’s three stories. It weighs 100 tons. And I just absolutely cannot fathom saying I’m gonna buy an offtheshelf gantry

David Raubach: and build our own beam line to go through. I like I just it takes a lot of ambition to think that you can do that. Niek Schreuder: Well, you have to understand that Indiana University was was kind of one of the leading institutions uh you know worldwide in terms of beam control and steering the beam and and you know they just had tremendous amount of uh experience and today the the pronova system you know that that Indiana technology that was developed in Indiana University eventually was licensed into the pronova system. So, David Raubach: okay, Niek Schreuder: what you see today operating in uh at this Nashville facility is pretty much a replica of the beam we built in

Niek Schreuder: the early days at Indiana University with a very rapid fast switching. David Raubach: Uh that was the only system in the world you can really move the beam between rooms in 3 milliseconds. It was never really implemented that way but uh that’s what Indiana University developed to split the room to to share the beam between multiple nuclear physics users for for having effective use of the beam. So that technology made it into the medical field and and it was great. Fantastic technology, right? David Raubach: So then talk about because you end up leaving Indiana University uh and joining Procure. So just talk about that evolution and what the idea for Procure was early on and who some

David Raubach: of the key people were. Niek Schreuder: Yeah. So in in 19 1998 97 in South Africa we realized we need to figure out a way that we can also treat more than just incraanial treatments. It was just after the folks at PSI started treating with benser beam scanning and Dan Jones my Dan was a legend also he passed away a couple years ago but he was a legend in South Africa worldwide also in the proton therapy space he said Nick why don’t we build a a a base system that is not based on gantries but based on pens beam scanning so I wrote a paper in 1998 saying that you do not need gantries but you

Niek Schreuder: need an incline beam system where one beam is horizontal and Another one is uh 30° off the vertical and we wrote a paper uh we had Dr. John Munen writer he was at the Harvard cyclone MGH and he came back and said well I agree with you guys if you have this device you don’t need a gantry but it was based on three principles you needed to it will only work well with pens scanning and you need to have 3D volutric imaging so that I can actually uh scan a patient supine and then bring the patient in the upright position and I also need to rotate the patient around in the Bmax. So it was

Niek Schreuder: basically a description of an upright system but you had an additional beam that is not completely horizontal. Right? So uh 2004 five John Cameron said you know there ought to be a way to get more patients treated with protons and that pathway is not these expensive four five room centers. Why don’t we go and build your incline beam concept? So one gantry, two incline beams and one fixed room. And we also set that point and this is a point that is completely lost in in all the business model said we want to refer 15% of patients away to the academic centers. Right? So if you start doing the math you can treat 30% of complex

Niek Schreuder: cases on the gantry you know the middle 60% you treat on uh you know the incline beams and then 10% on the fixed beam room and the rest you sent back to the academic institutions that was of course based on that you have an over supply of patients David Raubach: so never pensive beam scanning took 10 years later only became clinical 10 years later pretty much eight years later um code beam GT was never implemented and u the robotic positioner we didn’t have really a proper chair system they can rotate the patient and of course the patients were were were not there so you literally you know you literally had to treat every single patient that

Niek Schreuder: comes through your doorstep right you didn’t have the privilege of being collective right David Raubach: and that’s why that model failed now you know if proid would have started up today with the technology we have today it would be a roaring success Niek Schreuder: yeah well talk so but talk about um because I do think there was a a a good mission with Procure and that was to bring proton therapy into a community setting. It doesn’t always have to be at the big academic research facilities and it was to bring the cost down of putting facilities in and then that those two things combined together create more access for patients. And so I do think it was

David Raubach: a beautiful vision that John Cameron and you and Niek Schreuder: uh then kind of uh bringing in Hadley Ford and Chris Chandler and some of the early people that were involved. So just talk about that early team and how the company got put together. Niek Schreuder: Yeah. Yeah. Right. I mean so we actually started another uh before before Procure we had another company that started out of Indiana University and we called it community proton concept. CPC was the company but Indiana University said okay guys you want to do that please resign do it on your own and of of course all of us couldn’t do it and John Cameron at that point retired uh you

Niek Schreuder: know after 25 years a really phenomenal career path at Indiana University um came from Obera Canada and so he he retired as the director of the lab and and then started broker and and and connected with Hatley for and u started procure based on this principle. Now the the fundamental principle is you do the same thing over and over. So that’s why these these facilities were exactly pretty much the same design. So you immediately save millions of dollars just on the architectural cost of not having to redesign the building David Raubach: and and standardize but but I think the whole principle was there at that point it was modeled to try and treat 160 patients a

Niek Schreuder: day which came from the numbers at at Lolinda and uh that would have worked at 160 patients then we had up to 10 up to 10 facilities were supposed to be constructed but then the 2008 David Raubach: uh economic turndown came and a lot of these facilities then never got built, right? And of course the patients never I mean there was a there was a key decision point in the history of broken where we needed where we had a decision to be made about you know shall we actually start building two room centers and not these four room centers Niek Schreuder: right David Raubach: uh but I think it was already kind of too late it would have

David Raubach: been hard to get them financed and so uh I mean you know there’s not a single one room center or a two room center that’s not full Niek Schreuder: but there’s only four room centers that that’s half of them. All right. Or empty. David Raubach: Right. Right. Right. So that so the first center ends up being in Oklahoma City. So the Oklahoma Proton Center and it opens in August of 2009. So how did that project come together and just talk about what your role was in in putting that project together here in Oklahoma City? Niek Schreuder: Yes. So my uh actually my bigger my role was of course promoting the old concept that you don’t need a gantry.

Niek Schreuder: So we keep on showing and I spent a lot of time showing the distribution of the patients and the complexity and and how we would send 15 patients back to our academic friends and uh back referral to to people and they would send us the the easy patients. That was kind of the that was kind of the thinking but in Oklahoma of course with uh with Aubry Mlendon there and Hadley’s good ties with Aubry ended up with uh Dr. Go and so well here’s the first site. I mean it was it was incredible to find the willingness in the community practice to to build the facility. So my my role then was primary to continue

Niek Schreuder: to train all the staff recruit physicists but we also put together the training center. You know it was projected that we would be so overwhelmed with starting up these facilities that we built our own training center in Bloomington Indiana. Um that was basically a replica of the facility but no proton. So we had a a fully working proton therapy center without protons. We we had a simulator. David Raubach: Well, you had a model gantry, right? Niek Schreuder: Yes. Yes. Everything. David Raubach: Yeah. Niek Schreuder: And we actually installed cone beam CT in that gantry. We we did cone beam CT on a phantom in that gantry in Oklahoma. David Raubach: but it was just deemed I mean that is

David Raubach: one looking back at my past that was one mistake that I made not to push for cone beam CT in in the gantries or even in the fixed beam rooms based on a robotic position. It’s the same robot that we have in the floor to position the patient. We just mounted the exact same robot in the ceiling to make a C arm go around the patient and it it really worked well Niek Schreuder: but it became too expensive. Right. And uh already in 2010 I showed that we can actually do treatment planning of that cone beam CT. But uh you know looking back it’s always hindsight’s always the best site. David Raubach: That was the mistake not

David Raubach: to push the volutric imaging at that point. Niek Schreuder: Yeah. What who made the X-ray machine? It was basically the Electa the Electra XVI system that we just David Raubach: took all the parts from Electa and the robotic positioner was made by Fort Automation and it it worked beautifully. David Raubach: Yeah, that’s amazing. So in Oklahoma, one of our claims to fame here is that we also had a chair. Niek Schreuder: So uh talk about that chair that you the treatment chair that you made for the center. It’s it’s still up on our mezzanine. So at the proton center here, there’s the treatment level and then there’s the administrative level David Raubach: and then the third level is all the

David Raubach: power supply systems and cooling and it’s also storage and so the chair is sitting up there but we used it to treat patients here in Oklahoma and a similar chair is being used in Chicago. So just talk about the idea for putting that together and what we treated and how it got built. Niek Schreuder: Yes. So that chair uh is very is is a this is the basically third I I started before I left South Africa we we were doing the upright the incline beam system. So we had a robotic positioner and designed a chair that would go on top of that. that engineer that worked for me in South Africa then came and we contracted

Niek Schreuder: him to do a design for us at at Indiana University the so-called Midwest Proton Therapy Institute and and we treated patient in that similar but it was not as stable uh as stable as we would want it to and then so when we went with Procure we hired the engineer that worked with me at Indiana University and so we then developed this this chair but this time around the chair was actually we just designed it but it was fully commercialized and FDA approved uh through a company that used was QFIX. It’s now part of the CIFO. So QFIX actually developed the whole thing. We prototyped it at the training center in Bloomington. Spend hours and

Niek Schreuder: hours working out the degrees of freedom and and all the problems overcome the problems and then the yes the first patient treated in Oklahoma with WC and uh the physics team there at Oklahoma. Um the the missing link at that point of course was an upright CT scanner. I mean so again you were treating the patient but you really can only treat intercraanial because everywhere else outside the cranium the anatomy changed too much uh and the form and and you need to make those corrections right. So that that was a that was my fourth chair that well third fourth chair and then I started working with the PQ system and and came up with the

Niek Schreuder: idea of a beach chair where you need to stretch the patient’s legs out in front of the patient David Raubach: so that the patient can rotate over the robotic arm right so you so that you can make a full 360° and that’s that concept that they then added to the facility in Chicago which was then commercialized by by Pier and now treating patients uh in Israel in a seated position. David Raubach: Yeah. And so uh so from Procure and I do want to kind of finish out the history here. So Proure ends up building centers in Chicago, uh Seattle, and Princeton, New Jersey. All of those centers were four room facilities. They’re all still open. They’re all

David Raubach: still treating patients in Oklahoma. I don’t know if you know this, Nick, but we have actually treated patients from all 50 states Niek Schreuder: in 16 different countries. David Raubach: Wow. Um, and we still have we still have patients that travel from around the the US for treatment here in Oklahoma and we’re we’re coming up on 7,000 patients treated. Niek Schreuder: That is remarkable. David Raubach: So that’s a Niek Schreuder: Yeah. So that’s an amazing legacy uh here. And then and then the other procure centers too. Um right David Raubach: and I think you know maybe the all four of the procure centers had to go through a financial restructuring. Um, I think that’s that’s well known. But I do think

David Raubach: that one of the legacies with Procure is that Procure did an amazing job and your team did of really pushing the field forward in in terms of figuring out how to immobilize patients, how to treat, how to get the treatment planning done quicker and more efficiently, what were the right beam angles to use, what types of cancers could be treated. So, we don’t have 50 proton centers today in the US if Procure isn’t doing what they’re doing to move the field forward. Niek Schreuder: Right. Yeah. and and I would say uh protons in many many regards would have been dead. I mean if you look at the history of systems sold between 2004 and 2010 majority

Niek Schreuder: of those systems were sold by was bought by procure uh right David Raubach: and uh you know people can claim you know it didn’t work but it really saved the industry through to through to through that drive and in trying to trying to bring the cost down. So I mean there was pretty much you know the cost but about maybe $180 million of proton therapy equipment was sold in in the worst drought in history in terms of protons. David Raubach: Right. So Niek Schreuder: yeah right after 08. Yeah. Exactly. David Raubach: Right. So it was still three I mean it was still three three centers were sold after the ’08 during that incredible crisis. Right. Uh yeah. And so

David Raubach: I I look back and say, you know, yes, maybe people can say the thing didn’t work, but we really saved the proton therapy industry. And Niek Schreuder: yeah, certainly in the US. David Raubach: Yeah. So then, um you go and join Provision. Um and I ended up at Provision with you. We sat down the hall from each other there in Knoxville, Tennessee. And we lived down the street from each other, actually. Niek Schreuder: You had you had the farm. I had the bigger farm. David Raubach: Yep. Niek Schreuder: So I think you you probably had more animals. David Raubach: More animals. Yeah. So Niek Schreuder: yeah. Um and you’re still there in Knoxville. Um so just talk a little bit about

David Raubach: that journey to Knoxville and working at Provision and working with developing the Pronova system. How do you look back now on on those years there with Provision and Pronova? Niek Schreuder: I I I think you know Chronova then towards the end of the procure lifetime we realized I mean maybe we need gantries maybe the gantries need to be smaller right and uh so then John Cameron and Anfroof developed together with the folks at MIT the superconducting gantry and at that time the pro project in Knoxville came along and u Dr. Douglas started Pronova together with Joe Mateo and Larry and a lot of other folks. I mean, we shouldn’t really name names here because we’ll definitely leave

Niek Schreuder: names out, but they developed the world’s smallest gantry, but the smallest gantry still required a three-story building and and the total project costs remain the problem. So, I just keep on pushing and say, can we do upright? Can we do upright? I did meet with the old Prnova team in 2013 and say we should build an upright system but you know it was just too foreign and people just didn’t think and it was unfair for me to expect that they should understand it but I just came out of South Africa where we treated 500 patients upright and everybody at the Harvard Cyclone Lab was treated upright. So we knew it could be done David Raubach: and

Niek Schreuder: I knew it could have a tremendous uh uh reduction in not not in the equipment but in the total project cost right and u so then eventually the smallest gantry still was not able to sell because the total project cost was just too much and at that point it was very clear you’re just not going to get this the 120 150 patients a day to to finance these these these systems right so finally Um I you know joined forces with Rock Mackey and uh after provision failed to secure financing for building more centers or uh you know pronova or provision healthcare then uh I had to I had to go and so at that point

Niek Schreuder: was just the timing was just right when uh Rock and Steven started Leo cancer camp David Raubach: and your what’s your title with Leo? Niek Schreuder: Uh I’m the chief scientific officer for Leo cancer care and my primary role was now again I was still doing the same where I had to promote telling people that the procure system can work. Now I had to stop telling people oh we can’t actually work uh upright but it’s important that the upright system we’re working right now was designed from first principles by physicists and physicians to treat in the upright position. It was not an afterthought. was not something that was designed for treating patient in a lying down position and

Niek Schreuder: they say now can I put a chair on a robot to also have in a seated position it’s designed from first principles to treat in the upright position knowing all the difficulties from day one and that’s what that’s why we now seeing such enormous success uh in in the adoption of this technology David Raubach: well and and maybe uh flesh that out a little bit so enormous success what does that Niek Schreuder: Uh well I mean if if you think about we we partnered with um we partner we we partnered with everybody in the proton therapy space except of course one of the vendors doesn’t want to work with us and I’ll stay away from naming any names

Niek Schreuder: but uh David Raubach: okay Niek Schreuder: we have now uh you know if you think there’s 42 proton therapy facilities um in United States and and Mevon you know Mevon developed this world’s smallest accelerator and I saw from day one when we started developing leo cancer if you can take that accelerator off the gantry put it on a pedestal on the floor and marry it with our system it can be the world’s smallest machine um so we met with the first time in January 2020 um they initially said you know can they just sell the cyclron to us and we said well that’s a great idea and then 3 weeks later they said no no we’re not

Niek Schreuder: selling our cyclone and then a year or two later David Raubach: they constitute the mavon fit machine so meon fit now has seven contracts just in the United states plus several more outside the United States. U and so think about it. Um I can probably disclose the number of about 10 11 fit systems under contract in the last two years versus you know that’s a that that’s that’s a quarter of the proton facilities in the last two years just only because the total size of the product is so much smaller. So we used to say, “Oh, the proton machine fits on a football field and now can it go on a half a football field and

David Raubach: then can it go in a tennis court?” Niek Schreuder: Yeah. Or a tennis court. Yeah. Right. David Raubach: And now it fits in the paint of a basketball court, Niek Schreuder: right? David Raubach: Yeah. Niek Schreuder: Well, and and I would also add that it fits inside of many linear accelerator vaults. And that’s always been David Raubach: Yeah. That’s kind of been the the holy grail in terms of what do we have to get to in terms of the size of the system to be able to significantly expand the number of proton centers there are in the United States. And I think fitting inside of a LANC vault was really the ultimate goal because there are so many LANC vaults in

David Raubach: the United I mean there’s thousands and thousands of thousands. I’ I’ve seen numbers as many as six or seven thousand linear accelerator vaults Niek Schreuder: in the United States. And so if you can get to the point where you’re not always having to build these big threestory buildings and even if you add on something that is the size of a linear accelerator vault, you’re significantly reducing the cost versus adding on a gantry. David Raubach: Yeah. And it’s also cooling all the the infrastructure you need to just cool down the building. But I want to make a very important point here that the listeners would really hopefully take home. Right. So in the past because these proton machines

Niek Schreuder: were so expensive you have to be able to treat every patient coming through your door right so now we saying we treating upright and people say can you treat all the patients now I believe we can I mean there’s there’s some patients that is too sick but they probably wouldn’t get the reimbursement for protons anyhow so you can take them out but think about it now I have a device let’s say let’s say I I believe we can treat all the patients but let’s say we can treat 60% of patients David Raubach: now I can treat 60% of patients that never had the ability or opportunity to treat protons. And so don’t throw the baby out

David Raubach: with the bath water and say let’s start catering for that. Let’s say 30% of your patient must get protons. They can now get protons, right? It’s not a problem that you have to treat. So you actually be Niek Schreuder: the proton industry strugg struggle big time from have to be jack of all trades in the end of master of none. So because we needed to treat everything, we needed to do this large field size this and this and this and didn’t really allow us to specialize it. So where I see the future is now these machines are now significantly reduced in cost. The total project costs are significantly reduced and we can start specializing on certain

Niek Schreuder: disease sites. I mean we know which cancer benefit tremendously from protons. So we can now start developing a machine where we really deliver proteins superbly accurately on this machine right and and I think this is where we go David Raubach: well and maybe talk about that because um one of the challenges that we had early on and even when the procure center opened in Oklahoma City in 2009 is that there there just hadn’t been that many patients treated. I mean there there were thousands of patients treated but when you really think about that in the context of there’s almost two million patients getting diagnosed with cancer every year in the United States it was a very very

David Raubach: tiny percentage of patients and so one of the things that we didn’t have was good was uh robust expansive long-term follow-up data on thousands of patients because you’ve got to get these patients enrolled on clinical trials and then lots of cancers are very unique you know, you might only treat I mean, at the time we might have only treated uh 20 breast cancer patients total in the United States with protons in 2009. Well, now we treat thousands of breast cancer patients. And so, it’s a lot easier now as you have more centers open to collect more data of what’s happening with the what does survival look like? What do side effects look like? And I

David Raubach: think what we’ve seen over the past few years is you’ve seen some really compelling clinical studies coming out validating the benefits of proton therapy. all the everything that we theorize Niek Schreuder: about if you can stop the beam, stop the radiation inside the tumor and avoid that exit dose, you’re going to have fewer side effects. Well, now we’re actually seeing that play out. David Raubach: And so maybe like what’s your perspective on on all of that and what’s happening clinically with protons? Niek Schreuder: Yeah. Know I I think that that is definitely true. I mean, of course, we always know that Chris Chandler always said, “I never find a doctor that said I don’t want protons. I just

Niek Schreuder: can’t afford it.” Right. So now if you if you can fit that doctor you know here’s another important thing the the modality the process has to fit into your clinical program it even if it cross this across the parking lot it cause a problem with the doctor can’t be in two buildings at the same time so I I think we know which cases will really benefit for protons and I just want to say in the upright scenario is that the the cancer that’s the most difficult to treat supine these are the abdomen pelvis because everything moves around with breathing is now superbly stable in the upright position. So I think those targets uh so prostates

Niek Schreuder: uh you treat a prostate in upright position. You do not have to worry about bladder fill anymore. You don’t have to do bladder management because David Raubach: the prostate doesn’t change position whether the bladder is full or empty. It’s the f one of the first studies that I published on uh working with Leo. So so I think you can think about the patient now just walk in go stand argument sake stand against the post the scandal comes down and treats. So I’m actually now pushing for what I believe autonomous treatments and autonomous treatments is where the patient is fully guided under camera uh 3D vision systems. We know exactly where the patient is any given moment

Niek Schreuder: and we just made a scan. So I think and then of course with AI where we can really do these auto segmentation and I mean I think the future is extremely bright to reduce the manpower not taking people’s jobs away but everywhere I go there’s underutilized machines because there’s not enough therapists right and and so if we can reduce the man the need for manpower not even to talk about the third world in developing countries I I think the future is extremely bright all I need to do now is to get this vision to somebody that can help me develop it. And so we don’t have to develop out of sales, you know, to to

Niek Schreuder: develop these things out of sales is just a hard act for any company. U David Raubach: but we really need to see somebody to see the vision and we really need we really need an Aubrey McClendon’s vision again to say now what do we need to to really fuel this process to make protons really affordable and then then we can start specializing in specific disease sites. So I’m I’m foreseeing a device what I call a pelvatron. A device that’s just completely designed to treat tumors in the pelvis, right? And then something for treating tumors in the thoracic space and for head and neck space, right? And breast, right? Oh, I love it. I love it. Always

David Raubach: the visionary. So, in the last couple minutes that we have, describe to me what you feel like your legacy is in the proton therapy space because I think if there’s a Mount Rushmore of proton therapy, you’re you’re definitely a candidate to be on it. Um, and it’s and it’s possible that you’ve been involved if you count the four Procure Centers plus South Africa plus IU plus Knoxville and then helping open up Nashville. you’ve been involved with treating more proton therapy patients than just about anybody in the world at this point and you you that’s kind of part of your legacy, but what do you what do you think that your legacy is or what do

David Raubach: you hope people think of when they think Nick Schroeder and proton therapy? Niek Schreuder: Well, I mean I I just hope that uh yeah, I mean I I think my legacy is probably the amount of people that I trained that I involved and and my energy and enthusiasm that I that I was able to to transfer to people when I moved to United States. You know, South Africans love barbecue. And so I had a friend Paul said, you know, it’s one thing about Nick. He’s passionate about protons and barbecue, right? So I still love my barbecue, but I still think, you know, I I became really disillusioned at some point where where the protons and there’s

Niek Schreuder: a lot of people in the proton industry, they want to keep it expensive, right? And I will just I you know, I I am a I’m a straight shooter. You know, if somebody just spent millions and millions of dollars on a big system, they really don’t want to see something come up that is less expensive, right? But again, I think these big systems, expensive systems could remain in the academic centers and and the less expensive systems. And I I really want to make a point that upright is not only about cost reduction. It is in certainly a better way to treat a patient. The patients love it. The patient can participate and there’s so many

Niek Schreuder: other things that we can exploit now. So coming back to the legacy, I’m hoping people look back and say, you know, just that continuous push, continuous push to say, can we do something? Uh, you know, and I I I I should have started that. I grew up on a farm, very remote farm. There’s if somebody if the tractor breaks, you can’t call somebody to fix it. You have to fix it yourself. David Raubach: So my legacy is about fixing things and solving problems and seeing a solution for a problem, you know. Uh, so you know that that’s great. But I just want to say one other thing I forgot to say earlier. I have to give

David Raubach: credit to a guy Ben Harris. Niek Schreuder: And when you talk about Oklahoma City, we have to always remember Ben Harris’s contribution. He was there on my physics team and unfortunately Ben passed away early from ALS. But you know, Ben should carry a lot of credit for getting Oklahoma sitting on time, on target on first treatment, right? David Raubach: Well, that’s a good point. I mean, that center uh start to finish was a 24-month construction, and that had never been done before. I mean, the the thinking up to that point was you need 3 to 5 years to get a proton center for Niek Schreuder: with a brand new robotic positioner. First time ever we had that robotic

Niek Schreuder: position to treat a patient. David Raubach: Yeah. Right. Yeah. Well, that’s amazing. Thank you, Nick. Uh you’re a good friend. Um we don’t get to see each other enough since I moved back to Oklahoma City from Knoxville. I know uh the farm’s still running well, so that’s great. Um, but thank you for taking the time to come and talk to us today, Niek Schreuder: David. Thank you very much for inviting me and it’s a joy talking to you and it’s uh let’s let’s uh let’s see the future. I think the future is superbly bright. David Raubach: Well, I plan to carry your vision forward. So, Niek Schreuder: thank you. David Raubach: That’s my goal. All right. Thanks, Nick.

Niek Schreuder: Thanks, David. David Raubach: The Cancer Project podcast is made possible by the Oklahoma Proton Center, a state-of-the-art cancer center where precision and treatment meets real compassion in care. We’re grateful for their support and for you for spending this time with us. If you’d like to learn more about the Oklahoma Proton Center, you can visit their website at the link below. And if something you heard today resonated, we’d love for you to stick with us. You can subscribe to the podcast and follow along on our socials linked below for more conversations like this. Honest stories, thoughtful perspectives, and the kind of support people don’t always know where to find, but do truly need. At the end

David Raubach: of the day, this podcast isn’t just about cancer. It’s about what it means to be human inside of it and how we keep living, connecting, and moving forward together. We hope you leave each episode feeling a little bit more informed, a little bit more supported, and a lot less alone.