Chapter 14: Bringing Proton Therapy to MD Anderson
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Description
In this chapter, Dr. Komaki describes the first steps in the process of bringing a proton therapy center to MD Anderson. She first underscores that she supported such a center because it was her dream to have the best methods available to avoid radiation toxicities in normal tissue. She lists some of the secondary effects of conventional radiation treatment.
She talks about the financial context in the late eighties and how Dr. James Cox, MD [oral history interview] was able to move on this project when he became Head of the Division of Radiation Oncology, securing fifty percent of the support from MD Anderson and the University of Texas system and the remainder from private funding. (The Proton Therapy Center opened in 2006.)
Next, Dr. Komaki talks about the controversy over the value of proton therapy. She also describes efforts she and Dr. Cox made to find the best proton system available, eventually setting on Hitachi.
Dr. Komaki then explains how she was able to intervene when contract negotiations with Hitachi broke down, using her fluent Japanese and her cultural knowledge to convince the CEO of Hitachi not to back out of the deal.
She next sketches the slow increase in patients after the Proton Therapy Center opened in 2006, some problems confronted, and the difficulties of getting insurance reimbursement for proton therapies.
Identifier
KomakiR_04_20190123_C14
Publication Date
1-23-2019
Publisher
The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center
City
Houston, Texas
Interview Session
Topics Covered
The University of Texas MD Anderson Cancer Center - Building the Institution; Building/Transforming the Institution; Multi-disciplinary Approaches; The Researcher; Personal Background; The Business of MD Anderson; The Institution and Finances; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; Definitions, Explanations, Translations; Global Issues –Cancer, Health, Medicine; Fiscal Realities in Healthcare; The Healthcare Industry
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
T.A. Rosolowski, PhD:
Okay, our counter is moving and today is January 23, 2019, and I’m at the home of Ritsuko Komaki, for our fourth session together. Thank you for joining me, or allowing me to join you.
R. Komaki, MD:
Thank you for coming.
T.A. Rosolowski, PhD:
With green tea and good conversation. Oh, I’ll say for the record, it is about 25 minutes of ten and I guess we’re ready to roll.
T.A. Rosolowski, PhD:
We were strategizing a little beforehand and you said it would be a good time to talk about the Proton Therapy Center. Tell me, how do you want to start that story, because there was sort of a dream of doing it.
R. Komaki, MD:
My passion to have the best treatment for patients, especially young or pediatric patients, by radiation treatment, was to avoid any toxicity to normal tissue surrounding the tumor, because when I started to get training to be a radiation oncologist, we did not have any sophisticated equipment or planning software. Some of the patients, they started to live long enough after radiation treatment. With or without chemotherapy or surgery, they started to have normal tissue toxicity, including second malignancy, like patients with Hodgkin’s disease. They developed breast cancer, or thyroid cancer, lung cancer, or other cancer later on. Of course, those patients who had the one cancer, they do have slightly higher probability to develop second malignancy, compared to people who never had cancer before. General population, it’s about 3 percent incidents to develop cancer, but those people who got chemotherapy and radiation treatment, they have much higher instance to develop second malignancy. To avoid normal tissue toxicity as well as second malignancy, what would be the best way to treat those patients? That was always my passion, because coming from Hiroshima, I saw those young people, infants, who were exposed to low dose of radiation to total body. Like Miss Sadako Sasaki, she was an infant who received low dose of total body radiation and she developed leukemia when she was 9 years old. I started to think about how we can avoid exposing low dose of radiation to pediatric or young patients, because once we achieve the goal to cure, facing a second malignancy is really devastating. Sometimes within the radiated area, what can we do? It’s a very difficult problem. Sometimes we remove it. Sometimes, if it’s unresectable, then we have to re-treat by radiation treatment. But adding radiation treatment, even ten years or 20 years after a previous radiation treatment, it might cause osteonecrosis or pericarditis or lung fibrosis. It’s a challenge for us. So when I came to MD Anderson Cancer Center in 1988, I thought, this place has space to put a new equipment such as proton and also, a lot of patients including failed to the original treatment, secondary malignancies, with a lot of financial support. Some of the patients, they donate the money for the research and some equipment. So I started to think about putting a proton center at MD Anderson. But not at the beginning, because my husband, Jim Cox, who was the vice president of patient care, and physician in chief for five years, he was so busy. Eventually, he became divisional head and chairman, after Dr. Lester Peters: he decided to go back to Australia. So that position became vacant, and among 22 candidates, Jim Cox, was chosen to be division head and chairman of Radiation Oncology. When he became the divisional head, I asked him, “Can you please put a proton center here?” The first thing he said, “Well, we don’t have money.” He’s a very honest and no nonsense man. He said, “We just don’t have money, it costs $250 million, including space, equipment, so what can we do?” He got 50 percent financial support from MD Anderson Cancer Center UT System supported by the State of Texas. Then the other 50 percent, was supported by private investment people, and that was the start. We went all different places, to look for what’s the best proton equipment.
T.A. Rosolowski, PhD:
Where did you go to look?
R. Komaki, MD:
Okay. One was in Belgium, IBA, and the other one was in South Africa. They had a big, big equipment, very old, and they were treating just pediatric patients. They were treating 25 patients a year --they were all inpatients--and they just stayed there to be treated, and most likely they had a brain tumor. That was a beautiful setup, because in the backyard, giraffes were running around, and peacocks were flying. But we said no, this is too old and too big and we cannot afford to get this old equipment.
T.A. Rosolowski, PhD:
Let me ask you a question, because from the reading I’ve done, and I’ve interviewed a number of people about the Proton Therapy Center and kind of what was going on and all that, and in my reading, as I was doing background reading, I was discovering that there was actually quite a lot of controversy over the value of it.
R. Komaki, MD:
That’s right.
T.A. Rosolowski, PhD:
How effective. So I’m wondering how were you factoring that into your thinking about this?
R. Komaki, MD:
Right, okay, so they were—around that time, avoiding low doses of radiation to the normal tissue, especially for children, that was kind of debatable. Also, with proton therapy, how we can control tumor motion? And looking at the image: are we hitting the right place? That was not established very well. I received a scholarship to go to Tsukuba University, where they had Hitachi Proton. This was a research institute at that time and Hitachi’s proton equipment and treatment were supported by Japanese Government Grant support. They were treating patients free because of grant support. I went there by [the invitation of Professor Dr.] Akine, who got the Japan Society for the Promotion of Science --he received a grant to bring me there to see how the proton works. So I went there for one month under this grant, JSPS. I stayed there and I checked all those patients: how they were treated, and how this proton works. The proton spares skin and it hits right in the place where the tumor is. When it hits the tumor, almost a hundred percent energy, it puts it there and the exit dose is very low. So, compared to an intensely moderated radiation treatment, (IMRT), that scatters the low dose of radiation to the normal tissue around the tumor --and that’s not very good for growing patients, like the bone and brain, normal cells dividing, and that’s not good for children. So proton, it’s more focused. It’s really targeted to the tumor, and that’s what I really wanted to get here.
T.A. Rosolowski, PhD:
What year did you go to Tsukuba?
R. Komaki, MD:
Tsukuba, I went there in March 2004, and then we got this Hitachi proton equipment later in 2004, and we opened Proton Center 2006 to treat patients.
T.A. Rosolowski, PhD:
Right. Now I remember when I was interviewing Dr. Cox, he told me that you had a real hand in some of the negotiations with Hitachi.
R. Komaki, MD:
Yes.
T.A. Rosolowski, PhD:
So tell me about that.
R. Komaki, MD:
Okay. While we were in Japan, we visited Hitachi Proton Center. The main office was in, we call it Ochanomizu, O-c-h-a-n-o-m-i-z-u. Ochanomizu. That’s the place in Tokyo where they had the main office, so we went there, Jim and myself. We went there to meet with CEO of Hitachi and I started to talk to them in Japanese. And five CEO people, one of them said I have a Hiroshima accent in Japanese and Hiroshima dialect. So I said, I came from Hiroshima, and he said he came from Hiroshima, and we found out that we were same year in the same Hiroshima University Affiliated High School.
T.A. Rosolowski, PhD:
Oh really? How amazing.
R. Komaki, MD:
And we never met after we graduated from high school, like 40 years. He went to engineering at Tokyo University and I went to Hiroshima University Medical School, so we never met.
T.A. Rosolowski, PhD:
What’s his name?
R. Komaki, MD:
His name is Mister Sumikawa, and I said, “you know, we graduated from the same high school in the same year, I trust you, and I want you to make sure the maintenance would be precise, well maintained and guaranteed.” Because this proton center, when Jim got this 50 percent from private founder, if the machine goes wrong, if the machine goes down, the investment people will lose a lot of money. Hitachi had to pay that deficit. Say we are treating 50 patients a day. If the machine goes down and they have to fix it, and it takes maybe one week or two weeks. Who is going to pay that money? So we had to go through Hitachi business people to guarantee that they will maintain the equipment, and not break down, and if machine goes wrong, they have to pay the deficit. They were very annoyed by signing all agreement by the investment business lawyers because Hitachi is a very established company in Japan. They do not only make proton, but also they make the Shinkansen, the bullet train. They make escalators, they are a conglomerate, the huge big company. They make TVs and all those things. So when the MD Anderson Proton Center Investment group was requesting their signature through their lawyer to make sure they will pay any deficit of the equipment, or financial loss when the machine goes down, Hitachi executive people were not happy to sign them.
T.A. Rosolowski, PhD:
So was the idea that Hitachi felt that they were insulted?
R. Komaki, MD:
Insulted. They really have high pride and in Japan, they know they have very good equipment. And we trust them, but see in the United States, this is the first time to put the proton center from Hitachi, or anyplace. So we had to go over every step. From this side, from MD Anderson, they had to put a lawyer: every step they had to sign when we decided to get this Hitachi Proton. They started say, “well, I’m not sure to deal with you to sell the Proton Machine to MDACC. If you don’t trust us, you know the proton is not a big deal for our business, so we’re going to withdraw.” My husband came to my office. That was 6:00 p.m., and Japanese time was ahead, like eight o’clock in the morning of the next day. He said, “You have to talk to Mister Simikawa, he’s aware and he has to sign all those documents.” He had stacked up all the documents to be signed on his desk and it might take three months before he really gets signature. So Jim asked me to call Mr. Sumikawa, and I called in Japanese, and his secretary answered. She asked me who I am, so I said I’m his old friend and I have to speak to Mister Simikawa right now. She said, “well, he’s not here but he can call you back about one hour from now.” He called me back and so I told him the system in the United States: we require his signature at every step, and a lawyer’s signature from our side. We are not distrusting or insulting Hitachi. This is the business we have to go through in the United States. I had to explain this to him in Japanese, and he said, “Okay, I’ll sign it.” So he signed it immediately; otherwise, we started to think—that Hitachi might withdraw this business. You know it was so annoying, every step they have to sign. So we were desperate to make sure this proton center will be open in 2006. We found out that Hitachi wanted to get this equipment shipped to us, but we had to push them to do it and I had to explain the difference between U.S. and Japanese business system.
T.A. Rosolowski, PhD:
Sure. Those things really matter.
R. Komaki, MD:
It does. So I explained it to him and I could speak Japanese well. Also, we are old friends, from the same high school, so it went through. When he came to visit the MDACC Proton Center, when we got this equipment, we had a wonderful reception and he did karaoke. We had a great time with hope of high technology from Japan. We finally opened the Proton Center to treat patients in 2006. At the beginning, we had 20 patients, but within one year, we started to increase the patients to 75: after one year we were treating about 75 or 80 daily.
T.A. Rosolowski, PhD:
Now... I’m sorry.
R. Komaki, MD:
Yeah. The problem we faced was insurance reimbursement. They said, “We don’t reimburse the cost of proton treatment since proton is not standard treatment.” Oh my gosh, we had to struggle, the insurance coverage. Pediatric patients, we did not have much problem. At the beginning, prostate cancer patients, they really wanted to get the proton treatment: it’s sparing the rectum and the bladder, and so they don’t get many side effects. But insurance company people started to argue: oh, low grade prostate cancer, they can do implants, they can do surgery, and why do you have to use proton? There was some randomized trials, IMRT and proton, and there was not much difference in the toxicities and survivals between patients treated by IMRT and proton.
T.A. Rosolowski, PhD:
And this was a study you conducted?
R. Komaki, MD:
No, no, that was prostate cancer, and lung cancer, unresectable, or a lot of patients with lung cancer who had surgery first and the cancer came back. They wanted to get chemo and proton treatment to spare the normal tissue because you know when it came back, usually it came back right next to the major critical organs, like the heart and lymph nodes, trachea and it was unresectable because of the location of the recurrent cancer. So how we can treat? Combine chemo and radiation treatment without causing normal tissue toxicity, that was the major issue. So the proton should be the best way to treat those unresectable lung cancer.
Recommended Citation
Komaki, Ritsuko MD and Rosolowski, Tacey A. PhD, "Chapter 14: Bringing Proton Therapy to MD Anderson" (2019). Interview Chapters. 1295.
https://openworks.mdanderson.org/mchv_interviewchapters/1295
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