Targeting Cancer More Effectively

Proton Therapy Institute at UF/Shands Jacksonville Brings Promise and Prominence

By Lynn M. Thompson

Jacksonville is about to hit the big time as a cancer treatment destination. In July of this year, the University of Florida Proton Therapy Institute will begin offering cancer patients a new treatment option that’s painless and virtually free of side effects. It will be one of only four facilities in the nation to offer the most advanced cancer treatment technology available today, all courtesy of the tiny little proton.

With traditional radiation therapy, high energy levels of X-rays are passed through the body to destroy the cancerous tissue, but they also damage surrounding tissue and any other cells in their path. Protons enter the body at a much lower energy level and release the majority of their energy only when they come into contact with the tumor itself. This minimizes damage to adjacent tissue, enabling a low incidence of side effects from the treatment. This also makes proton therapy perfect for tumors in sensitive areas of the body.

The protons themselves are made from plain water. Oxygen is removed from the water molecules, then electrons are stripped from the remaining hydrogen atoms. The remainder consists of pure protons, which are injected into a cyclotron and accelerated to 95% of the speed of light. Once at this speed, the protons are directed into a pipeline and guided by magnets into one of the institute’s gantry rooms. Lasers help to position the patient so the proton beam can be directed to the appropriate part of the body. Electromagnets keep the beam on track and decelerate the protons to a level that is both safe for treatment and the proper speed to specifically target the patient’s tumor from several angles. Treatment continues daily for a four- to six-week period.

The idea of bringing the 98,000-square-foot Florida Proton Institute to Shands Jacksonville originated with Dr. Nancy Mendenhall, a UF radiation oncologist. Dr. Mendenhall had been the chair of UF’s radiation oncology department since 1992, and felt the need to envision where the field was going. “I saw that we were moving toward conformal dose distribution,” she says. “With conventional radiation therapy, the dose of radiation going to normal tissue surrounding a tumor precluded our giving as high a dose as was needed to eliminate the tumor itself.” The institute will be staffed by a team of radiation oncologists, physicists, engineers and computer scientists, with Dr. Mendenhall serving as Medical Director.

Protons are not completely new in the radiation oncology field. Patients were being treated with them at research centers as early as 1991, when Dr. James Slater began pioneering work in the field in his facility at Loma Linda University Medical Center in California. Advances in imaging technology made it possible to define the tumor target for the very specific proton beam. But there were problems with positioning the patients accurately to deliver the correct dose to the tumor, so the therapy was used only for types of cancer that could not be treated with conventional radiation or surgery.

Proton therapy is best suited to tumors in the head, neck, lung, breast and prostate, as well as for treating children. Dr. Slater released the results of his studies in 1998, about the same time Dr. Mendenhall was becoming involved in the radiation oncology department at what would become Shands Jacksonville. She began to realize that the facility would be appropriate for a clinical proton facility.

Mendenhall approached UF College of Medicine Dean Ken Burns about proton therapy and how it differed from conventional radiation. “He immediately understood the concept,” she says. “One of his top strategic missions for the college at that time was to play a stronger role in cancer treatment. And one of the university’s top strategic missions was to develop programs that crossed disciplines and colleges. A proton beam institute was the perfect fit. It was just a matter of my being in the right place at the right time.”

But facilities involving the latest medical technology are not built overnight, nor are they built on a shoestring. A task force was appointed to study the idea, headed up by Dr. C. Craig Tisher, who has since replaced Dr. Burns as dean of UF’s medical college. “About a hundred people worked on this, and I’ve never seen such determination,” says Mendenhall. “We examined all the clinical and technical issues surrounding bringing this institute to the region. Dr. Tisher’s refusal to give up, no matter what obstacles were in his way, was truly inspiring.”

One of the first things the task force recognized was that UF couldn’t start on this project without some help. The State of Florida understood the importance of the institute and contributed $11 million through two appropriations in 2000 and 2001. “That allowed us to investigate the institute, covered all the legal studies that needed to be done, and gave us ten percent of the funding to get started on building it.”

The City of Jacksonville also stepped up to the plate. Dr. Mendenhall made a presentation to the Jacksonville Economic Development Council to explain the idea. She and Dr. Tisher met with several commissioners and council representatives to make sure they understood what this institute would mean to the city. The citizens of Jacksonville delivered on a $19 million low-interest loan to Shands, and floated a $62 million bond issue for the purchase of the institute’s equipment from Belgium. Not to be outdone, the equipment manufacturer, Ion Beam Applications (IBA), contributed toward the project. Private donations made up the remainder of the $120 million of funding, and construction began in the spring of 2003. Design work was done by Tsoi/Kobus & Associates of Boston, while Perry-McCall Construction Co. of Jacksonville constructed the building.

To fully understand the support for this institute by all these underwriters, it’s important to understand Dr. Mendenhall’s background and original vision. Named in 1999 as one of the top 318 cancer specialists for women facing breast cancer, Dr. Mendenhall has spent her entire medical career working at UF. Her many publications, participation in research projects, and service with boards and societies in her field have yielded distinction among her peers and made her uniquely suited to this new position as medical director of Florida Proton. “The first thing we want to do is provide every patient with the greatest possibility of cure with the lowest side effects,” she explains. “Some cancers are well treated with traditional radiation therapy, and they can continue to be treated with it. But this institute brings a unique resource to this part of the country. The closest proton facilities outside of Jacksonville are in Houston or Boston. People will be coming from all over the southeast to seek treatment here.

“But its full potential is not just in treating patients. We will be incorporating clinical research into the institute’s operations. Treatments by protocol will be provided to the maximum and documented. Its optimal role is apparent, in documenting the benefits of the treatments.

“A third goal is to be a platform for other clinical oncology research. Things like vascular targeting agents and better chemotherapy. We will work with other departments in the college and with other institutions on this. Studies will be done on health care costs, information transfer and accuracy within the system. Shands will end up being a national resource for radional effects and cancer care.

“If we fulfill that mission, Jacksonville will be seen across the nation as a center for research and cancer care. All kinds of new people will be drawn into the community, from patients visiting for treatment, to highly-educated professionals working with the institute. So it will have not only a positive economic impact on the city, but build Jacksonville’s reputation for scientific research, both basic and clinical.”

The institute will work closely with the Mayo Clinic Jacksonville, which is investigating a proton center for its Rochester facility. Dr. Mendenhall has also met with representatives at Nemours Children’s Clinic and Baptist Medical Center to discuss collaborative efforts involving the new proton institute. “We will be treating patients with both conventional radiation and protons, and will work with Jacksonville’s medical community on this, although many who seek treatment at the institute will be coming from outside of the city.”

Dr. Mendenhall has a personal interest in the areas of lymphomas, breast cancer and pediatrics. The institute will be developing specific protocols for treatment of tumors in the prostate, lung, brain, sarcomas, and advanced cancers of the breast and gastrointestinal tract. The treatment is also effective for eye disorders such as macular degeneration.

Proton therapy will not replace mastectomy for breast cancer patients, as the cancer is not localized enough to save the breast tissue if surgery is recommended. In such cases, surgery and conventional radiation therapy are the most effective treatments. “There’s not a lot of room for improvement there,” she says. “But with advanced breast cancer, traditional radiation makes it difficult to give the high doses of radiation that are needed to combat the tumor without damaging adjacent tissue. We won’t be using proton therapy at the beginning for this, but it will come later.” Traditional radiation therapy will be provided by the institute, in addition to proton therapy.

One gantry of the facility will open in July, while a second and third will follow later in the year. Each gantry is three stories tall, and rotates around the patient bed to allow the proton beam to be directed at the tumor from any angle. A fourth, stationary, proton delivery device is more appropriate for treating things like nonmalignant eye disorders. When fully operational, the facility will be able to treat up to 200 patients per day.

“The equipment in this facility is unbelievably impressive,” says Stewart Klein, the institute’s executive director. “There’s a huge device in each gantry that looks like a Ferris wheel that’s used to position the beam appropriately for the patient.”

In addition to the proton facility at Shands Jacksonville and the original one at Loma Linda, Massachusetts General Hospital in Boston has one, and another in Houston is coming online later this year. The facility at Shands will include clinics for pre- and post-therapy and on-site treatment evaluation of patients, treatment simulation and planning suites, an infusion and anesthesia suite, social and dietary services, a research office and faculty offices.