1. Comparison of Clinical Parameters for Proton Therapy in the United States Paige Summers, MS

2. Disclosure This project is supported by the Federal Share of program income earned by Massachusetts General Hospital on C06 CA059267, Proton Therapy Research and Treatment Center and by grants CA10953 and CA81647 (NCI, DHHS).

3. RPC Background Funded by the NCI, tasked with ensuring that radiotherapy institutions participating in clinical trials deliver clinically comparable and consistent doses Asked to develop monitoring program for proton therapy facilities too

4. Proton Therapy Facilities Monitored by RPC: 10 clinical sites 1 international site in Japan Forecast ~20 new centers Will likely see increase in clinical trials with proton therapy, making comparability important NJ 2012 Shizuoka 2003

5. Proton Approval Steps Proton facility questionnaire Annual monitoring of beam calibrations by the RPC Ability to electronically transfer treatment plans Irradiation of RPC’s baseline proton phantoms On-site dosimetry review visit

6. Information Collected by the RPC Typical review components: Dosimetry equipment calibration CT scanner, CTN/RSP conversion Patient immobilization Treatment planning procedures QA documentation

7. Patient Simulation Parameters InstitutionScannerkVpmAsSlice ThicknessAcquisition ModePitchSFOV [cm] 1GE LightSpeed RT 161406001.25 mmAxialN/A50 2GE LightSpeed RT 161203002.5 mmHelical0.9450 3Philips PET / Big Bore120 / 140500 / 4001.25 mmHelical0.51 / 0.5665 / 85 4GE VCT1203502.5 mmAxial/Helical N/A / 0.9450 5Siemens Biograph 16 PET120 / 1401501 mmHelical0.5550 6Siemens Sensation1203001.5 mmHelical0.7550 7GE LightSpeed RT 161402501.25 mmHelical0.9450 8GE LightSpeed RT 161203001.25 mmHelical0.9850 Values obtained during on-site audit Can institutions improve simulation imaging parameters? Lower CT dose?

8. Treatment Margins Described by institution in facility questionnaire Site-Specific Lateral Margins [mm] BrainH&NAbdomenPelvis Institution 12.5355 Institution 23355 Institution 33355 - 8 Institution 4577 - 97 Institution 52222 Institution 6335 - 75 - 10 Institution 75555 Institution 833 - 55 - 103 - 5 Institution 92255 Institution 103555 Institution 115510 Penetration Uncertainty Margins Institution 13% Institution 23.5% + 3mm Institution 31.50% Institution 43.5% + 3mm Institution 52 mm Institution 63.5% + 3mm Institution 71% + 1mm Institution 81.5% + 1.5mm Institution 9- Institution 101% + 1mm Institution 113.5% + 3mm

9. Prescribing Dose Prescription Levels BrainH&NThoraxAbdomenPelvisExtremities Institution 195 - 98% Institution 295 - 98%- 97.5%- Institution 395%92%95% Institution 4100% Institution 5100% Institution 698% Institution 795% Institution 898% Institution 995% Institution 1095% Institution 1195% Institutions normalizing in different ways, to different levels

10. Significance Differences exits across centers Task groups focusing on QA, papers on outcomes – not many recommendations about clinical parameters - could use more recommendations from experienced proton centers Important to consider variation of dosimetric parameters in planning clinical trials – proton alone or mixed modality

11. Questions? ??

12. Proton Approval Steps Proton facility questionnaire Annual monitoring of beam calibrations by the RPC Ability to electronically transfer treatment plans Successful irradiation of RPC’s baseline proton phantoms Successful completion of on-site dosimetry review visit

13. Facility Questionnaire AAPM Proton Advisory group aids RPC & QARC in updating proton facility questionnaire Submitted to QARC via email or paper – copy sent to RPC Questions covered: Experiences in the clinic Dose calibration & verification Proton beam production & delivery Treatment Planning Immobilization Patient Alignment QA

14. RPC Proton Site Visits Typical site visit measurements Beam calibration comparison – RPC/Inst CAX lateral and depth dose profiles for reference and patient fields Scanning beam – less fields tested, more profiles obtained X-ray system measurements TLD measurements