This episode is presented solo by host David Raubach. Transcript generated from the episode’s audio; automatic transcription may misspell names and terminology. Please refer to the video for the authoritative version.

I want to thank you for joining us on today’s episode of the Cancer Project podcast. Today I get the opportunity to talk about a place near and dear to my heart, the Oklahoma Proton Center. I want to tell those of you that are potentially interested in coming to the facility for treatment or want to know a little bit more about what we do just talk about who we are, the history of the center, cancers that we treat, what to expect when you show up to the facility. So, first off, I think it’s important to start with the history of the facility. So, the Oklahoma Proton Center opened in August of 2009. When it opened, it was just the sixth proton center in the country. The first proton center in the United States opened at Loma Linda University in 1990.

After Loma Linda, you had proton centers open at the University of Florida Proton Therapy Institute, the University of Indiana, MD Anderson Cancer Center, and then Massachusetts General Hospital, which is the teaching hospital for Harvard University. Then a group of doctors in conjunction with the local hospital system partnered with a company called Procure to develop the first private proton therapy facility in the United States in right here in Oklahoma City. Construction started in 2007. As I mentioned, the center opened in 2009. Today, we’re treating over 700 patients a year. We’ve treated over 6,000 patients since we opened in 2009. We’ve had patients come from all 50 states and 15 different countries for treatment.

If you think about back when there was just six proton centers in the United States, you had a lot of patients that needed access to proton therapy that didn’t have it in their local communities. And so we had all of these patients that were coming to Oklahoma City for world-class cancer care. And today we’re still one of just five proton centers in the southwest and one of just two proton centers in the state of Oklahoma. And so we get patients that travel from northeastern Oklahoma, from the Tulsa area, from around Wichita, southern Kansas, the panhandle of Texas, northwest Arkansas, and then from time to time do still get patients that travel from as far away. We actually had a patient that came from Alaska for treatment recently. Another question that we get is what types of cancer do we treat at Oklahoma Proton Center?

So really, if you think about proton therapy, what we’re doing is we’re taking a high energy beam of proton particles, these subatomic particles that exist within the nucleus of an atom, and we’re accelerating them to really, really high speeds. In fact, our cyclotron or particle accelerator can actually accelerate protons to two-thirds the speed of light. To put that in perspective, the circumference of the Earth is 25,000 miles. So if you’re talking about two-thirds the speed of light, that’s a speed of about 120,000 miles per second. So at 120,000 miles per second, that proton can circle the Earth almost five times in 1 second when it comes out of our cyclotron. That’s how fast these proton particles are traveling. We then take this beam of high energy proton particles and we are able to target them directly at cancer cells.

And so if you think about what types of cancers can be treated with proton therapy, you really need to think about do we have a target to shoot the beam of protons at and does this target show up on imaging. So really any solid tumor that shows up on diagnostic imaging like an MRI or a PET scan or a CAT scan can potentially be treated with protons. And these are things like brain cancers, breast cancers, head and neck cancers, lung cancers, prostate cancer, soft tissue cancers, lymphomas, GI cancers like liver cancer. So a lot of different cancers we can treat. Ocular melanomas is another cancer. And we can treat cancers in the pediatric population as well as in the adult population.

The reason that proton therapy can be beneficial for cancer is that with protons we have the ability to stop those particles inside cancer cells. So to put that another way, when we talk about delivering radiation into the body, our goal is to deliver as much radiation to the cancer cells as possible and as little radiation to healthy tissue. So more radiation to cancer cells, less radiation to healthy tissue. And because with protons, we’re able to stop that radiation inside the tumor, we’re able to spare healthy tissue and critical organs beyond the tumor from exposure to radiation. Additionally, protons deposit less energy as they’re traveling in to the body before they get to the tumor than another type of radiation, X-ray radiation, which is frequently the alternative option or the alternative type of radiation that can be used to treat cancer.

So, there’s less radiation going into the body and then no radiation beyond the tumor. Whereas with X-rays, you get more radiation along the path getting to the tumor and X-rays cannot be stopped inside the body and so they’ll continue traveling beyond the tumor and hit that healthy tissue and those critical organs and deposit radiation and that can result in side effects for patients. I want to talk a little bit about what those specific side effects can be. So we’ll start with breast cancer. With breast cancer, a lot of times you have very radiation sensitive or radiosensitive organs and structures in close proximity to the field that you’re trying to treat.

Specifically, the heart a lot of times and especially for left-sided breast cancer patients or breast cancer patients where we’re having to treat the internal mammary nodes, the inner part of the chest, that heart a lot of times can be right near or even in the radiation field. So it becomes really really critical to do everything possible to reduce or eliminate dose to the heart going through treatment. The heart is also really really sensitive to radiation. It doesn’t take a lot of radiation to potentially do damage to the heart and we’re talking about even potentially severe damage up to the point of a heart attack or heart failure for patients years down the road after treatment.

And so when we create a proton plan, we’re coming in with that radiation field and we may come in with one field or we may come in at a couple of different angles and we’re able to craft the treatment plan in such a way where we’re delivering most if not all of the dose into the breast or into the chest wall and then stopping that radiation or stopping that beam of protons before it ever reaches the heart. Whereas with X-rays, we do everything we possibly can to try to keep that dose off the heart, but again, because of the physical properties of X-rays, because they can’t be stopped when they go inside the body, a lot of times it’s really, really challenging to deliver all of the radiation that we need to all of the areas where there might be cancer cells while completely eliminating dose to the heart.

One of the phrases that we’ll use is know your gray. What do we mean by that? When we say know your gray, what do we mean? Well, we measure radiation in units called gray. So, gray of radiation is a metric or a unit of measurement for an amount of radiation. When we prescribe radiation for cancer, we the doctor is saying there’s an amount or a total dose of radiation or a total amount of gray of radiation that we want to deliver over the full course of treatment. And a lot of patients getting radiation will get treated for multiple days, maybe 5 days, 10 days, 15 days, all the way up to 40 or more days of treatment. So, we’re delivering a little bit of dose or a little bit of gray of radiation each day. That adds up to that total prescription dose of radiation.

Well, to put the amount of radiation in perspective that we’re delivering to treat cancer, one gray of radiation is equivalent to tens of thousands of dental X-rays. So, the amount of radiation that’s delivered with one gray of radiation into the body is the equivalent again of receiving tens of thousands of dental X-rays. If you think about the last time that you went to the dentist, it’s likely that if you got an X-ray, the tech that was administering that X-ray provided some type of shield or some type of protection for your chest as you were getting that X-ray. They were concerned about the amount of radiation being delivered by one dental X-ray getting into the chest and hitting the heart.

Well, think about that times a thousand or 10,000 or a 100,000 and that’s the amount of radiation that we’re that is being used to treat breast cancer. So, it becomes really really important to understand and think about the gray of radiation or the amount of radiation that’s potentially being delivered to your heart. So when we say know your gray, literally what we’re saying is know the gray of radiation or know the amount of radiation that your heart is being exposed to going through treatment. And your radiation oncologist has that information. They have the ability when they go in and they do the treatment plan, they’re looking at the amount of radiation that’s being delivered to the area that needs to be treated, the cancer cells or the tumor, but they’re also looking and assessing the amount of radiation that’s going to other critical structures.

And so you as a patient can ask the question, how much radiation or what gray of radiation is being delivered to my heart and is there any way to reduce that? At the Oklahoma Proton Center, all of our patients are assessed for both proton therapy and traditional X-ray-based or photon radiation therapy. So, this is traditional radiation versus proton therapy. And our doctors look at the comparison between those two treatment plans and they look at the amount of radiation that’s going to the tumor as well as the amount of radiation that’s going to healthy tissue. And they compare the two and they say, “Okay, are we doing are we getting all of the radiation to the tumor that we need to with proton therapy and with traditional photon or x-ray based radiation?

A, and then B, what’s the comparison in the dose to these critical structures or these healthy tissues such as the heart for breast cancer?” And then we say we want to pick the treatment plan where we’re delivering the least amount of radiation to healthy tissue while getting the prescriptive dose that we need to the tumor. So I want to transition to another cancer and talk about another cancer and the impact that excess radiation can have. So head and neck cancers are frequently treated with radiation. Now there can also be chemotherapy involved. There can be immunotherapy. There can be surgery involved but radiation is often part of the plan and these can be cancers of the tongue, cancer of the tonsils, cancers of the throat, nasopharyngeal cancers are going to be cancers that are in the nose area in the nasal cavity.

And there’s other cancers involved in the head and neck area. If you think about it, there’s a lot of really sensitive critical structures. And specifically one of the things is you have your swallowing muscles there and you have your throat that can potentially be within the radiation field. And so one of the challenges of treating head and neck cancer is ensuring that patients are getting everything they need from a nutritional standpoint. So are they getting are they getting the calories that they need? Are they getting the liquids that they need as they go through treatment? And a lot of patients end up needing feeding tubes in order to get or supplement the calories and the nutrition that they otherwise are not getting going through treatment as there’s damage to those swallowing muscles.

So a recent randomized study that came out of MD Anderson looked at the difference in the feeding tube dependency or the feeding tubes that were required for patients getting traditional radiation versus patients that were getting proton therapy and these were oropharyngeal cancer patients and this was a randomized trial. So the doctors randomly assigned patients to either get traditional radiation or to get proton therapy. And what they found was a 13% absolute reduction in the feeding tube dependence for patients getting proton therapy versus patients getting IMRT, which is the really the state-of-the-art most precise way at this point to deliver traditional X-ray-based radiation. So there was a big statistical difference in patients again needing feeding tubes if they got IMRT. There was a lot more dependence on feeding tubes with patients getting IMRT versus patients getting proton therapy.

So this is just another example of the type of impact or the type of side effect that patients can experience going through radiation treatment. If you think about this, this applies across all disease sites. So at Oklahoma Proton Center, one of our mantras is more than a cure, quality of life. So yes, pro our primary objective is to treat the cancer and kill all the cancer cells, but we can’t forget as we’re doing that the importance of ensuring that patients maintain a high quality of life or as high a quality of life as possible going through treatment. So another cohort of patients that we treat is pediatric patients. And if you think about it, pediatric patients or pediatric cancers really can have a devastating impact obviously just the process of going through treatment acutely, but these are the patients that are still developing.

And so when you talk about any type of intervention, whether it’s chemotherapy or surgery or radiation, and you’re going in and you’re having to intervene in a child, there can be life a lifelong impact for this treatment. So, there’s multiple studies that have shown that patients who received traditional radiation had more IQ loss or a bigger cognitive impact than patients who receive proton therapy for brain cancer. So, as you’re going in, you’re having to treat this tumor in the brain. Brain cells are developing inside pediatric patients. You’re going to have an impact when you deliver radiation into the brain and you hit those healthy cells. And that is measurable and that has been measured with again multiple studies where we’ve seen this bigger cognitive impact on patients receiving traditional radiation because there’s more exposure to healthy tissue or healthy brain cells in these pediatric patients.

And so again just to in conclusion with proton therapy we’re able to deliver less radiation to healthy tissue than with traditional radiation and so for a lot of patients that’s going to mean fewer side effects. So another question that we get asked is how do we know or how do I know as a patient if proton therapy is right for me? Well, the best thing that you can do is you can talk to a doctor who is experienced or skilled in using radiation and specifically using protons on a regular basis. We’ve seen a lot of times patients will talk to doctors and that particular doctor isn’t necessarily using proton therapy on a regular basis and that doctor will say well I’m not sure if you know I’ve heard good things about proton therapy but I’m not sure if it’s right for your particular cancer.

It’s imperative whether it’s talking to Oklahoma Proton Center or talking to another there’s now 45 proton centers in the country talking to another proton center to talk to a doctor who uses proton therapy on a regular basis to see if your cancer can be treated with proton therapy. And the other thing is that proton centers are the ones that actually have the treatment plans that are needed to create a specific treatment for a particular patient. And most facilities without proton therapy are not going to have access to this proton-specific treatment planning system to really specifically see for that particular patient how protons can be used and what benefit there might be to using protons to treat that particular cancer.

So if you want to know if proton therapy is beneficial for you, it’s important to talk to a proton center or talk to a doctor that’s using proton therapy on a regular basis. Another question that we get asked is what about insurance? Will insurance cover proton therapy? And that’s a great question because we know that going through cancer treatment is really really expensive and there can be a big impact for patients especially if they’re having to leave work or take time off or maybe it’s a an individual who is working who’s having to care for another patient. Cancer is expensive. The trickle down effect of going through cancer treatment can be really expensive. Having to travel for treatment can be really expensive. So it’s going to be top of mind.

Patients are going to want to know, is my insurance going to cover some or all of the cost of treatment? So, with proton therapy, specifically with Medicare, so a lot of patients are on Medicare. Medicare offers broad coverage for proton therapy. It’s very very rare, if ever, that we see a patient with Medicare not be able to get access to proton therapy treatment and have Medicare cover the cost of that treatment. And that applies to Medicare Advantage plans as well. On the commercial insurance company’s side and these are commercial plans through big payers like Blue Cross or Aetna or Cigna or United Healthcare as well as smaller payers. All of these commercial insurance companies are going to assess proton therapy and coverage for that particular patient on a case-by-case basis.

We have a fantastic team of financial counselors at the Oklahoma Proton Center who work with patients every single day to see what type of coverage those patients are going to have for their treatment. And I will tell you this too, a lot of times we see patients get told no initially by their insurance companies and then we go through an appeals process and we get those cases approved. So don’t ever let an initial no be the final answer if you’re again worried about coverage for proton therapy. And so these financial counselors will work with patients. They’ll figure out what the coverage is going to be with their insurance company or with that patient’s insurance company. And then they’ll also figure out what the out of pocket might be, whether it’s a deductible or co-insurance.

And the other great thing at Oklahoma Proton Center is we have a foundation called the Proton Pals Foundation. And one of the main purposes of the Proton Pals Foundation is to step in where there’s situations where patients can’t cover the full cost of their care or they have ancillary expenses outside of the direct cost of their treatment that they can’t cover. Again, things like housing, transportation, food needs, physical therapy, meeting with a mental health professional, and the Proton Pals Foundation can step in and help supplement or cover those additional costs that the patient can’t cover. So, if you have questions about insurance, again, reach out to the financial counselors at Oklahoma Proton Center and they can help you out. Another question that we get is how long does the process take? What should I expect if I call the proton center today?

How soon can I get under treatment? Well, the first thing that’s going to happen if you reach out to the facility is you are going to get scheduled to talk with one of our radiation oncologists. We have a fantastic team of doctors that work there on a regular basis. Dr. John Chang, Dr. Mark McLaughlin, and Dr. Mark Story. They’ve been working in the field of protons for many, many years. Have treated hundreds if not thousands of patients with proton therapy. They’re really really experienced and you’re going to get scheduled likely to talk to one of those doctors. If in conjunction with your physician, you decide that proton therapy is the best option for you, at that point, we would schedule you for a treatment planning cat scan. And this is a an image that’s acquired.

It’s a three-dimensional image of your body that shows us where the tumor is, but it also tells us what types of cells or what types of tissues those protons are going to have to travel through before they get to the tumor. And that tells us how fast we need the protons to be traveling when they exit the accelerator and then exit the beam line into the treatment room. At that point, how fast they need to be traveling to get to the tumor and then stop. And so we gather all this information at the treatment planning cat scan and then a team of dosimetrists. So this is the position or the name of the group of people that work with our treatment planning system. These dosimetrists then work in conjunction with the doctors on a patient-specific treatment plan for you.

And what they’re doing again is they’re figuring out what is the best way to get all of the radiation or all of the protons that we need to kill all the cancer cells. What’s the best way to get all of those to the cancer cells while exposing as few healthy cells and as few critical organs to radiation as possible this whole process from the CAT scan developing the treatment plan and then we will actually go through and we’ll deliver a mock treatment. And so what that means is that we are using a box that has radiation sensors inside of it. And we actually put that box in front of the proton beam. And we tell the software system that runs the particle accelerator and runs the beam delivery system to deliver your treatment, but deliver it into this box.

And we’re going to measure are the right number of protons coming out. Are the protons coming out at the right energy? Is the shape of the field what we expected. So we run through and we deliver an entire treatment as if it was your treatment into this box that detects everything that’s happening with that beam. And assuming that everything looks good, we would then let you know that we’re ready to start treatment. So frequently for patients from consult to treatment start, it takes about two to three weeks. If it’s an urgent case, sometimes we can move things along a little bit quicker.

If it’s a situation where a patient doesn’t necessarily need to start treatment right away, maybe they have a few weeks to wait, their cancer is a little bit slower growing, they need to get through some other treatments first, we can obviously push that out a little bit further, but about 2 to 3 weeks, from reaching out to the facility to getting other treatment is about what patients should expect. Another question that we get asked is, well, how do I know if the cancer’s gone? What what indication or what evidence is there? How do you know that this proton therapy treatment is working? So, there’s a couple things. One, again, we talked about the fact that we deliver these mock treatments ahead of time.

So, we know we have a good understanding of how many protons are going to be coming out of the beam line and at what energy and what shape of field. So, all of that information is ca gathered up front. Frequently we’ll do diagnostic imaging during or right after treatment and that gives us some visual indication of what’s happening with tumors. Now not every tumor is going to necessarily change in shape or size during or immediately after treatment. And sometimes we’re treating areas where there’s microscopic cancer cells. So for example with breast cancer treatment we might be treating an area where there was surgery done initially and we’re treating the surgical field or the surgical bed and so there’s not necessarily a big tumor that’s showing up on diagnostic imaging but we know that there’s microscopic cells still in the area.

So that in that situation and in other situations there might not necessarily be immediate visual evidence that the cancer’s gone but over time we should be able to see again using advanced diagnostic imaging evidence that the treatment has worked. The other thing is that some cancers emit biomarkers that can be measured. A lot of times that’s how we figure out that there’s cancer there initially. So a great example is prostate cancer. So prostate cancer one of the primary screening methods used is the measurement of prostate specific antigens that are produced by the body or PSA. And so if we see an increase in the production of PSA that can sometimes be evidence that there’s prostate cancer present.

And so then if we go through treatment and we’re delivering radiation to the prostate that was initially producing these prostate specific antigens and there was a spike in that production of prostate specific antigens, well we would expect to see the production of PSA drop back down to a more normal level or even below where it was prior to treatment when that patient was healthy. And so that’s another way that we can detect whether or not cancer is still present or whe or if the cancer is gone. We also know we’ve been using radiation to treat cancer for over a hundred years. And so at this point there’s literally millions of patients over the past 100 plus years that have been treated with radiation. And a lot of these patients were enrolled on different clinical trials.

At the Oklahoma Proton Center, we enroll almost every single patient that we treat on what’s called a prospective registry trial. And what that means is that prospectively or upfront, we’re agreeing with that patient to gather information about their treatment and then to follow that patient after treatment for 6 months, 12 months, 2 years, 3 years, 5 years. And then we compile that data and that allows us to look and see okay well we for let’s take lung cancer as an example for stage three non small cell lung cancer we’re delivering this amount of radiation over this period of time. What have we seen with patients that have been treated at our facility in terms of the followup for those patients? And is it what we would expect from a disease control rate?

And when we say disease control, what we mean is has there’s a few different goals when we talk about disease control. One goal could be completely getting rid of the cancer entirely. So this would be a goal of total remission. The cancer is gone. There’s no evidence of that cancer. Disease control and then we think about that over a period of time. So is the cancer gone one year after treatment, two years after treatment, 5 years after treatment, 10 years after treatment. So this would be disease-free again at a period of time. So that’s one component of disease control. There may be some cancers where we know we’re not ever really truly going to be able to completely get rid of every single cancer cell.

It’s kind of going to be this ongoing battle, but what we want to do is keep that cancer from spreading. And so disease control in that situation may be maintaining localization or for that tumor or keeping that cancer in one particular spot or one particular area. So that could be disease control as well. But what we’re doing again with our prospective trials is saying for cohorts of patients coming to the Oklahoma Proton Center is our disease control whether it’s keeping the cancer from spreading or completely eliminating the cancer is it comparable to what you see at other cancer centers especially other top cancer centers like MD Anderson and Mayo Clinic and Memorial Sloan Kettering that are using proton therapy and what we’ve seen is at the Oklahoma Proton Center is yes when We follow these patients years after treatment.

We’re seeing that same very effective disease control with minimal side effects using proton therapy that you see at some of these other cancer centers and what we’ve seen historically when we think about radiation treatment. And so again, there’s diagnostic imaging, there’s biomarkers that can be used to assess the cancer. We know what to expect from a disease control standpoint when a patient comes in and starts treatment based on the type of cancer that they have and the aggressiveness of that cancer. And so these are all things that we’re looking at and constantly assessing at Oklahoma Proton Center. Another thing that we talk about at Oklahoma Proton Center that’s really really important and we have a a great patient services team that helps assess this is the importance of creating a community as you go through treatment.

So we know that patients there’s been clinical studies that have documented this patients that have a network or a support system as they go through treatment have better outcomes. And part of the reason for that is that if that patient runs into issues getting to treatment, getting access to food, getting access to housing, maybe ensuring that that patient is staying on all of their medications, it always helps to have that support system around them to help them get through the process. But there’s also a stress component that can have an impact on cancer outcomes. As you’re going through treatment, as you’re going through chemotherapy, radiation treatment, proton therapy, whatever the case may be, immunotherapy, your body’s immune system is actually going in and helping fight the cancer. It’s also helping ensure that you stay healthy as you go through treatment.

Stress can have an impact on your body’s ability to a directly fight the cancer and b ensure that you stay healthy going through treatment. A community or a support system is going to help patients manage that stress. There’s also a solidarity knowing that there’s other patients or there’s other people that are walking through the same thing that you’re going through. And so when we talk about a community, the community can be family, but the community also can be other patients that are going through treatment, other patients that are going through proton therapy treatment. And so part of what we do at the Oklahoma Proton Center is we try to create opportunities to facilitate that connection and facilitate this opportunity for patients to meet each other and talk about what they’re going through and just create again that support system for patients.

And this is something that our PAR our patient services team helps facilitate. So I hope that what we talked about today was helpful as you’re thinking about proton therapy and how it can be used to treat cancer. And I hope that that was helpful information about the Oklahoma Proton Center. We have this amazing facility here in Oklahoma City that again has treated at this point over 6,000 patients since we’ve opened and have had fantastic outcomes treating a variety of different disease sites, breast cancer, prostate cancer, lung cancer, head and neck cancers, liver, esophageal, soft tissue sarcomas, ocular melanomas. And so if you’re a patient that has questions, you want to talk to a doctor or you want to talk to another patient that’s gone through proton therapy, definitely reach out to us at the Oklahoma Proton Center. We want to be a helpful resource.

Even if you don’t end up coming to our facility, the best thing that you can do as a patient is to be your own advocate. You are going to care about your body and your treatment more than anybody else. You should own that. It’s okay to get a second opinion and a third opinion to talk to patients that have gone through different treatments. You don’t just have to take the first option that’s presented to you. We like to think about and I and I’m a consumer of healthcare. I want health care to be a playbook. I want it to be a science. I want think that when I go to see a doctor that they’re just going through a checkbox and then they say, “Here’s your one option.”

But the reality is that for a lot of patients, they’re going to get presented with a lot of different options or they’re going to have a lot of different options. And that’s why it’s so important for you as a patient to educate yourself, to be diligent, to do your research, and to again talk to multiple different doctors before making a decision, especially on something that’s as complicated and sophisticated and difficult to treat often times as cancer. Each patient’s different, each cancer’s different. You be your own advocate and make the decision that’s best for you. So again, if you have questions, reach out to us at the Oklahoma Proton Center and we’ll look forward to talking to you again on the next episode of the Cancer Project podcast.