Chapter 06: Assessing Aggressive Radiation Treatment, Cost Effectiveness and Proton Therapy


Chapter 06: Assessing Aggressive Radiation Treatment, Cost Effectiveness and Proton Therapy



Media is loading


Dr. Almond discusses the debate among oncologists between using aggressive treatment, which may cure cancer but also give the patient complications, and moderating adverse effects, which may lead to cancer reappearing later. He also describes modern advancements in radiation oncology such as proton therapy, which is a new and precise treatment, and its advantages and disadvantages in this chapter.



Publication Date



The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center


Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Overview; Portraits; Overview; Definitions, Explanations, Translations; MD Anderson History; MD Anderson Snapshot; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; Technology and R&D; The MD Anderson Brand, Reputation; Patients; Patients, Treatment, Survivors; MD Anderson Impact; MD Anderson Impact; Industry Partnerships

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.


History of Science, Technology, and Medicine | Oncology | Oral History


Peter Almond, Ph.D.

Now, the big arguments that you always get are: are you sure you’re doing any good?

James S. Olson, Ph.D.

The bottom line question, is it?

Peter Almond, Ph.D.

No one’s ever shown that you’ve improved survival rates and all of that, and I always sort of say to those people, “All right. You know, your question is whether we should pour all this money into all these fancy new treatments and whether it’s worth it and whether we’re going to improve survival rates, if you are unfortunate enough to ever need the services of a radiation oncologist, I’ll give you a choice. Do you want to be treated how they were treating forty years ago or how they’re treating today?” And then the argument’s over, you see. Things are better and, in fact, survival rates are better. It’s very hard, but it’s the incremental, the small ones. But what’s better is the complication rates are much, much lower, treatments are much more safer and much more precise, much better given. It’s just better over all, so it’s not.

Hopefully, as you follow these down through . . .

James S. Olson, Ph.D.

That, to me, seems sort of true of surgery, of chemotherapy, that some of the major gains have

been in sort of preserving the survival rate with less damage.

Peter Almond, Ph.D.

That’s right. That’s a good deal. As I see it, for cancer treatment, it’s there. As I said, Fletcher was known for being really aggressive and that he was going to be aggressive with cancer. He was willing, and, of course, it was the patient that paid the price. He was willing to say, “I’m going to be aggressive.” I think he told the patients, “We’re going to be aggressive. There’s going to be a certain probability that you will have some complications.” But he always felt that tradeoff was worth it.

If you had that attitude, could get pretty good cancer control, then you can slowly make sure the complications get less, and you’re much better off. You start off sort of not accepting the complications, I don’t think you ever sort of move forward, because you don’t have the complications. Very often, you sort of hear people sort of say . . . They get treated for cancer with radiation if they’re with a radiation oncologist that is not aggressive, so they make sure the patient doesn’t get a complication. There used to be a lot of private radiation oncology, and I think it’s less and less. What happened is the patient would get treatment, wouldn’t get any complications, wouldn’t get any skin reaction. They got treated and maybe felt better for a little while, and then the cancer would come back. That was always, “Well, that’s just the nature of cancer,” or that’s an act of God or something.

Take the same patient, had they gone to an aggressive radiation oncologist where the patient gets some complications and the skin reactions, the patient will come out and say, ‘Well, I got burned up by that radiation oncologist,” and it’s all the radiation oncologist’s fault, even though they may be cured of their cancer. So you have those sort of two extremes. Fletcher pushed the envelope in aggressive treatment even though he had the complications.

James S. Olson, Ph.D.

Didn’t I just hear a story in the news about a survey of oncologists who don’t give enough of the dose because they want to reduce the side effects?

Peter Almond, Ph.D.

That’s always the idea. It’s been around for a long time, and it’s still as popular for chemotherapy as it is for radiation oncology.

James S. Olson, Ph.D.


Peter Almond, Ph.D.

Certainly, if you get out into the small sort of community of radiation oncologists, and if you get in then, of course, the trouble is medical liability and lawsuits are the problem. We’ve always

been very fortunate here because, I think, the documentation and radiation and then quality control and assurance have always been very, very careful. So I think for small independent people it’s difficult to do.

Anyhow, it looks to me now as though this question of the oxygen effect with neutrons has gone away. Some people would try to alter that ratio with sensitizers, chemical sensitizers were tried, chemical protectors were tried, hyperbolic oxygen was tried, and then suits, tourniquet technique, anoxic treatments were tried. So all them, but eventually, I suppose, it will eventually come down to some molecular treatment of radiation or other. I’m not involved with it. I think there is some interaction between some people who work on the molecular level and radiation to see whether those can

converge a little bit, which they probably will at some point.$$

James S. Olson, Ph.D.

What about all the hoopla about proton therapy? I think I just heard an ad from Loma Linda University the other day.

Peter Almond, Ph.D.

Proton therapy takes advantage only of the physical distribution of the radiation. There’s no sort of trying to manipulate the radiobiology of the tumor cells or anything of that. Protons, again, are charged particles. They tend to go into the body, and at the end of their range create a lot of ionization so the dose suddenly goes up. So they go in, and the dose increases at the end and then stops, so the protons have stopped.

If you can send in a number of protons with different energies, where you will go and radiation will give off their energy and stop, and you can sort of build up so they go in and sort of you could cover the tumor with dose, because you’ve chosen the energies to go in and some to stop at the front of the tumor, some at the end of the tumor. Used to think there was some biological advantage to protons, but there are not. But they are, and you can very precisely now choose these energies. You can again choose the dose to go very precisely around the tumor. No dose behind, no dose to the side, you tend to get very high doses just to the tumor.

In fact, Loma Linda was one of the first. They were not the first. The Russians have been doing it for a long time and the Swedish have tried it. But on a sort of poor scale sort of thing and on their own, Loma Linda did this. They sort of went out and got their funding built their devise.

Then Mass[achusetts] General, Hermann Suit [?], one of his great contributions was he always thought protons should be tried at Mass General. Then, of course, M. D. Anderson decided to get in it.

I will have to say this, that I’m not sure what the clinical results are today. Loma Linda should

have results. They’ve been treating long enough. Certainly for things like prostate and things, I think they should do very well. Mass General has treated some eye tumors, because you could send them into the front of the eye and deposit the dose right on the retina and nothing else.

They do that.

The trouble with protons are the machines that accelerate the protons are very, very expensive. Protons are difficult to bend, so they come out of the machine in a straight line, but to use them you’ve got to bend them onto the patient and then move then around. So the devices to do that become very big because they take very high magnetic fields to do that, and so the gantries that move around the patients are huge. You need to go over to our proton facility sometime and see them. It’s a very big engineering project to do that.

Lesley W. Brunet, MA, CA

Let’s stop [while I put in a new tape]. [Tape 2 of 2, Side A]

James S. Olson, Ph.D.

Say that again for the record.

Peter Almond, Ph.D.

Of course. It seems to me that in cancer therapy, nothing’s a sure thing when you go into it. I think, one, is cancer is a complex disease, and it’s always very difficult to know whether that the theories that you put forth to treat it whether they’re right or not.

James S. Olson, Ph.D.

Among you physicists then are there sort of inside jokes about this, that it may go the same way the Cyclotron did?

Peter Almond, Ph.D.

Well, no, but there are camps. Obviously there are camps. There are people who will say protons are the way to go because we can now really put very high doses where we want to put them, very low dose elsewhere in the body, and so this is the way to go, and less expensive if we can set it up so we treat a lot of patients and average the cost out. It may not be as expensive as we think it is. There are others who say the modern techniques now with the computer controlled linear accelerators and intensity modulated radiation therapy [?] calumniators and the devices called tomotherapy, which is another device which uses low-energy X-rays, there are people that say with X-rays and with these modern approaches, we can almost approach the same kind of thing that protons. So there are people that are in all these different camps. The cost of the protons is very expensive. But if it does prove out and there can be one or two national

centers for some sites, maybe it’s worth it. Again, I think it just has to be tried. I don’t think it needs to be tried everywhere. Loma Linda’s a good place, and I’ve known that group for many, many years. I think they’re doing a good job. But you wouldn’t want to go to a much smaller place. You don’t want to put it in. You’ve got to go to the M. D. Andersons and the Mass General and say, “Let’s see what we can get with proton therapy.”

I will say this, for example, on the neutrons, which was an expensive program, took a lot of time to do, but we learned as much about conventional radiation therapy from that project as we did about almost anything else. So we learned a lot, which helped what we’re doing today. We learned some radiation biology, we learned some physics, we learned things about fractionation and other stuff, which are still important today. So the modern programs start, neutron therapy did them okay. The knowledge that we got out of it has certainly been very helpful today, and that will come out of the proton project. Whether it’s really successful or not, we’ll learn a lot that will be applied in the future. That’s just the way one does things.

But it is a big project, it’s certainly on paper, and you never start out any of these projects without at least theoretically seeing a good advantage. That’s why you do it and hope that your theories and your ideas and things are right.

Conditions Governing Access


Chapter 06: Assessing Aggressive Radiation Treatment, Cost Effectiveness and Proton Therapy