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Setting up a proton therapy center in Denmark

By Morten Hoyer, Professor, Medical Director; Cai Grau, Professor, Director of Research; Ole Nørrevang, Chief Clinical Medical Physics; Dorte Oksbjerre Mortensen, Chief Radiotherapy Technologist 
Danish Center for Particle Therapy and Aarhus University Hospital

The Danish Center for Particle Therapy (DCPT) celebrated the treatment of the first patient on Tuesday, the 29th of January. This was the starting point of clinical operation after several years of work on the establishment and preparation of the center. DCPT is a national center with three gantries and one horizontal beam line that will receive patients for proton therapy from all over Denmark.

The first patient was treated for meningioma and during the next few months, we will treat only patients with brain tumors due to the relatively low complexity. We will ramp up the capacity in April and will begin treating other indications such as head and neck cancer, breast cancer and pediatrics. All relevant technologies were used from the first day of operation. This includes use of multi-field optimization, cone-beam imaging, and range-shifters. Treatment time of the first treatment was longer than an hour, but after only a few weeks, we are already down to an average of 30 minutes in-room time per patient.

We feel that we were well prepared for the clinical start. We had defined learning objectives for physicians, physicists, and radiotherapy technologists and created a program which included basic as well as advanced education and training. Our staff participated in the Varian training programs in Baltimore, Cincinnati, and at Paul Scherrer Institute and we had training by the Varian application specialists in our center at Aarhus University Hospital. In between the clinical commissioning of our equipment, our staff trained on procedures and performed end-to-end practice workflows in the treatment room.

DCPT professions and collaborating radiotherapy centers worked together to build up an efficient and safe workflow. We have held several meetings with the seven radiotherapy centers in Denmark and established a training program for their physicians and physicists with the aim to identify the relevant patients for proton therapy. This is an important investment for the sustainability of the patient referral to the center.

The case mix and clinical protocols for treatment of patients at the center has been developed in close collaboration with the Danish Multidisciplinary Cancer Groups (DMCGs). In Denmark, there are national multidisciplinary groups with surgeons, oncologists, physicists, radiologists, pathologists etc. for all the large cancer groups. All key DMCGs were invited to create national guidelines on selection of patients, e.g., using treatment plan comparison, define guidelines for target definition and organs at risk delineation, decide on national dose-volume constraints, and create principles for referral and follow-up of patients. Patient reported outcomes and clinical databases are available for the DMCG’s.

There are multiple prospective studies in the pipeline. The Danish Neuro-Oncology Group (DNOG) has a protocol ready for neurocognitive assessment of brain tumor patients. The Danish Head and Neck Cancer Group (DAHANCA) has prepared a phase III study comparing photons and protons in a model-based enriched population of head and neck cancer patients and a phase II trial on re-irradiation with IMPT. The Danish Breast Cancer Group (DBCG) will later in the year introduce a study on adjuvant radiotherapy of breast cancer patients with high cardiovascular and secondary cancer risks due to high normal tissue radiation exposure if modern photon techniques are used.

We acknowledge all our national collaborators for all their contributions, our local Varian team for their hard work and efforts during the weeks up to our clinical start, and the Varian specialist for providing their support during the start of clinical operation. It is a great feeling to get started, and it could only happen with support from all these people.

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