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A Drop In The Bucket:
Proton Therapy at the ASTRO convention

November 12, 2018

It was an eye-opener for me to visit the vendor area of the American Society for Radiation Oncology (ASTRO) in San Antonio in October, 2018. I have been very critical of this organization due to their resistance to proton therapy. Most of the ten thousand members make their living with photons (X-rays).

The gratuitous “T” added to their acronym is made clear by its different color. It should be ASFRO, right? Or ASRO? Maybe they didn’t want to resemble the American Society of Clinical Oncology (ASCO). Or maybe ASRO sounded a bit risqué.

As a result of my visit to the convention, I have a better feel for ASTRO. They are sincerely dedicated to fighting cancer and have amazing technologies with which to do it. I would not go so far as to call their motivation altruistic, as there are amazingly big financial forces at work here, proving my conclusion that a lot more people are making a living from cancer than are dying from it.

How I got to ASTRO is a story in itself. The price of nonmember registration was over a thousand dollars. Even for a nonmember to attend just the exhibits cost $485. However, it occurred to me to contact Augmenix, the company that makes SpaceOAR, a product from which I personally benefitted during my prostate cancer treatment. They responded by giving me a guest pass to get into the vendor area. I visited on three different days.

My attempt to get a press pass was unsuccessful. As the media person said, “Anyone can have a website or a blog.” That didn’t even get me a cup of coffee. She also made a very revealing statement, pointing out what she called a “considerable backlash against proton therapy.” It made a big splash a couple of years ago, she said, but now people think there are too many centers, some of which are not doing well financially. “Besides,” she added, “there have been no double blind studies showing proton therapy is superior. This year, it’s all about stereotactic X-rays.”

Sigh. Same old same old. X-radiologists continue for the large part to resist proton therapy.

Here is the display of one of the vendors, with a big emphasis on stereotactic radiotherapy for breast cancer. Nice try folks, but breast cancer in one of the areas in which proton therapy is exceptional, in that it spares damage to the lungs and heart. Yet, I recently read the 2017 report by ASTRO regarding their suggested insurance coverage for proton therapy, and breast cancer was mentioned only if the patient is in a trial or registry, as if the treatment were experimental. (I’ll be writing a separate article on that insurance paper.) Such an attitude is an affront to all cancer patients, especially those with breast cancer.

ASTRO says their approval awaits more head-to-head comparison studies between x-rays and proton therapy. Researchers have experienced a problem organizing such random studies, however. Everyone wants to be in the proton group. Since they could be randomly selected to receive x-rays, patients don’t want to risk that possibility. Such studies are hard to fill up. However, there is a major well-funded study of that sort being conducted right now. In a few years, the x-rays proponents will need to find some other reason for withholding their support for proton therapy.

But wait, let’s look at a comment on Astro’s own website:

“Patient-centered healthcare and health services research are increasingly driving clinical trial design, data acquisition and regulatory process considerations. These enhance the quality of care and improve patient engagement in both treatment and research. Increasingly, big data that includes patient reported outcomes is used to determine the best treatment strategy that provides the best quality of care.”

Oh, they use accumulated data from the patients themselves to determine the best treatment. Hey, that’s exactly the kind of statistics that proton therapy has been gathering and promoting for the past twenty-eight years, since the first center opened at Loma Linda in 1990. The tabulation of these patient-reported results have shown a dominance by proton therapy over other treatments. It is this very kind of information that I use in my writing to promote proton therapy.

My attendance at ASTRO helped me articulate exactly what it is that I do. I put a sign at the bottom of my name tag that said “Proton Therapy Advocate.” When I went up to a booth the proprietor would always glance at my name tag. I would then explain that I advocate for proton therapy not from a medical reasoning, but from the patient’s perspective. In such case, of course, all of those quality of life surveys really count. There is no doubt about support for proton therapy from those who use it and have experienced it. To them the arguments are not theoretical. For someone like the media person, the take on proton therapy is just a policy. For us patients, it is a life-changing decision. When insurance companies deny us coverage because of some position paper by ASTRO, the difference becomes personal. So important is this distinction that I briefly considered creating yet another website, called, but decided I already have enough work to do.

Look at this chart demonstrating the 2018 research subjects for ASTRO.

None of these involve double blind studies. They are worried about patient-reported outcomes, about normal tissues and side effects, and data analytics. Hey, let’s compare those to the same numbers for proton therapy and see how they stand up.

So, with no press pass, I was restricted to the vendor area. Or was I?? Maybe I could draw interest toward me, rather than going to them. So, I sat at a table by the market eatery (with long lines at Starbucks) and put out my sign.

Above: My sign.
Below: The line for food and coffee.

During the hour I sat there, not a single person joined me or even asked me what was going on. So much for that idea. I decided to go to the vendor area and check it out. As I made my way through the convention center, I was very impressed by the level of organization. Clearly this reflected experience producing the fifty-nine previous conventions (this was the 60th year), a high level of professionalism, and lots of money. According to their accounting for 2017, that year's convention resulted in more than nine million dollars in profit.

Above: There was abundant signage to direct people to the right place.

Above: In a single document, they listed all of the events, plus the names of the vendors and a map of the vendor area.

Above: A significant representation from Asia.

Above: I wonder, do they throw away the big ASTRO sign or do they save it for future years, in which case, where would they store them?

Above: There was no difficulty finding the registration counter.

Below: Upon entering the vendor area, one is struck by its immensity. It is lit up like Las Vegas.

These huge displays cost hundreds of thousands of dollars. Then, when I saw the folks that had humble little eight-foot by ten-foot spaces, I was struck by the system of free enterprise, starting small and some day perhaps reaching the big time.

Above: While the displays of the industry leaders were packed with people, this vendor waited for someone to talk to.

Below: Surprisingly, the Mayo Clinic had a similarly modest space.

Above: Varian had one of the largest displays. Founded in 1948 and headquartered in Palo Alto, it has 6,600 employees worldwide. I asked about their proton therapy equipment and was guided to one small area, as shown below.

Above: On the left is a model of their single room system, shown below. To the right is the wall summarizing their proton therapy pitch.

Above: Varian's single treatment room configuration.

Below: Their large sreen with video information about proton therapy.

I talked for a while with one of the representatives. I mentioned that proton therapy had some exposure in the vendor area, but not in the presentations. He was surprised, saying he thought there was more interest than that.

So I went over to search through the poster presentations, of which there were more than 2,000 accepted. These are one-page summaries of research that people have done. How can you possibly navigate through so many possibilities? They had it all on computers, which one could search by topic, name of researcher, or code number for the entry. So I took a look.

There were numerous topics, including specific types of cancer or organ locations. I looked for proton therapy under the topics of physics, research and patient outcomes. I found two such poster reports, although there may have been others under the specific cancer categories. I am sure protons represent less than one percent of the presentations. Here is one result, which had a favorable outcome in favor of proton therapy. QOL stands for Quality of Life. Since many treatments have serious side effects, quality of life is an important consideration and one area in which proton therapy excels.

RT sands for "radiation therapy." Note the language. Proton therapy has reduced declines. In other words, declines in quality of life are assumed to be the case for X-rays. Proton therapy has less decline, which is to say, better quality of life. As a patient advocate, this is exactly the point I make over and over.

I went to IBA for a short talk about a new proton therapy technology being developed at the Beaumont Proton Therapy Center in Royal Oak, Michigan, called Spot Scanning Proton Arc (SPArc). I didn’t understand very much, as the presentation went very fast and was technically beyond me. The center in Beaumont claimed a date in August represented the first time a patient was treated with this technology. However, I found an article on the internet from 2016 which described the result of using that technique on three patients. I believe it was from PSI, the proton center in Switzerland that has been on the leading edge of proton technology.

That article described the technology as follows: A SPArc optimization algorithm was developed that integrates control point resampling, energy layer redistribution, energy layer filtration, and energy layer resampling. I could see from the charts shown in the presentation that SPArc increased the accuracy while reducing both the dose and the treatment time. The article on the internet, from 2016, reduced the dose by up to 14%, reduced exposure to surrounding tissue by up to 60%, had a much improved conformity index, and reduced total delivery time by up to 67%. These are percentages of figures which are already excellent for proton therapy.

X-rays originally directed one strong beam from one direction, which did a lot of damage. They subsequently developed techniques that directed the rays from numerous directions, with smaller doses, such that the total dose received the the tumor was the same, but less to any of the individual rays within healthy tissue. I have doubted that irradiating that much area could be healthy in the long run.

Proton therapy originated with a single wide beam, which was shaped using apertures to conform to the shape of the target, thus improving accuracy. Pencil beam scattering was a huge jump for proton therapy,delivering the dose in layers and rows of spots, from a single direction.As mentioned previously, the folks at pCure feel they can treat cancer from a fixed beam, thereby eliminating the need for a gantry. Now, SPArc technology uses both the advantage of spot scanning and rotating the gantry to direct the beam from different angles. They likely got the idea from x-ray technologies like gamma knife, etc. But unlike X-rays, the purpose here isn't to minimize the effect to surrounding organs, which is already very low, but rather to conform even better to the tumor. When beaming from one direction there is always a little uncertainty at the far edge of the tumor. By rotating around the tumor, you can benefit from the accuracy of the front edge, by taking it all the way around (or in some cases, they described half of an arc, or even a quarter arc). The caculation from a single direction is very complicated, so I can't imagine what it is for an arc. This was a very interesting advance in my own exposure to what is possible with protons. My above explanation may not be 100% accurate.

I wish I was as excited with IBA, which is helping to conduct this research. I invested in IBA stock a while back, and so far, it is down by 54%. Ugh.

In their literature, IBA suggests that proton therapy is beneficial for 20% of all indications. I think that is a very low estimate, as you can tell from the title of my book, Proton Therapy: Revolutionary Treatment for 80% of ALL Cancers. Perhaps with SPArc they will raise that number.

Next I stopped at the SpaceOAR booth. These are the folks who got me a pass to get in. A woman behind the counter glanced at my name tag, took a moment to make the connection, and then said, “I’m reading your book. I love it because you tell it like it is. You aren’t beholding to anyone.”

I met some of the representatives. They buy my book forty at a time and use it in their training. Their motto says it all: A little space can make a big difference! That little gap created by the hydrogel gel that is injected between the rectum and the prostate prevents damage to the rectum. I call it “saving the bacon,” if you know what I mean. Otherwise, you get to have a water balloon inserted into the rectum for each treatment (all thirty-nine of them), a process I was happy to avoid. At the time it cost me $3,000 out of pocket, and worth every penny. Now it is approved for coverage by Medicare and insurance companies.

As a proton therapy advocate, I receive emails from people pondering what kind of treatment they want, or, sometimes, how to get proton therapy. I was talking with a man who lives very near the Texas Proton Therapy Center in Irving, near Dallas. He consulted with Dr. Lee, one of the great experts in the proton field. I was shocked by what the man was told. Besides wanting the patient to have two years of hormonal therapy, Dr. Lee also said they don't use SpaceOAR for some unspecified reason. I find that shocking. Perhaps that reason is that no one there is trained to do the injection, and so they rationalize not having that technology. Dr. Lee helped found the proton center at M.D. Anderson in Houston, and was a pioneer in pencil beam scanning. I read a book written by a prostate patient at M. D. Anderson who explained how he received the balloon every day. Perhaps they don't use it there, either. Like proton therapy Space OAR is new, just a few years old. Could they be resisting for the same reasons some people reject protons, saying it is new and still unproven?

SpaceOAR had a large presence at the convention, not just in the vendor area, but also all the way up the escalator.

They also had a lecture in the industry-expert theater by three doctors describing their product, one of whom was Marcio Fagundes, who was the doctor at Provision who injected the SpaceOAR into me. In 2015 he gave a lecture at ASTRO describing the use of SpaceOAR. He has since moved from Provision to the new proton therapy center in Miami, Florida. I don't know the status of SpaceOAR at Provision after his departure. I think right now, knowing what I know, if I were to be treated for prostate cancer I would go to that new center in Miami, with Dr. Fagundes. Incidentally, he wanted me to do hormone therapy also, but I declined.

Another vendor, RaySearch, which made the software that the dosimetrists used to determine my prostate cancer treatment, had ads on the side of city buses. Go figure. They are located in Stockholm, Sweden, and have a worldwide presence with their software. They seem like a very progressive place to work.

From a humble beginning, ProTom has really gone big time. They went bankrupt a few years ago during their very first installation in Flint, Michigan. They have a small proton system that uses a synchrotron and needs less shielding. As a result, they can install the whole system in the space taken by two LINACs (Linear Accelerators, which are X-ray rooms). That is a huge advantage in cost savings, since you don't need a custom-built building. Apparently someone else saw the potential and stepped up to the plate with big bucks which led to their current high visibility within ASTRO and elsewhere. They are just finishing up their installation at Massachusetts General Hospital in Boston, which already has a proton capability (and where protons were researched since the 1960s), but not pencil beam scanning. I’m guessing ProTom can come in well below the price of other purveyors of proton equipment.

The only proton therapy treatment center that I saw represented was Provision CARES in Knoxville, where I was treated. They also have a division called ProNova, which builds innovative proton therapy equipment. Provision is developing several other centers. The one near Nashville just opened, while the ones in Orlando and New Orleans are in progress. I know they are interested in coming to San Antonio, but they haven't found the right partner for a collaboration.

I visited Sumitomo Heavy Industries and Hitachi, both of whom have been very slow to develop their proton therapy products due to the inherent conservatism of Japanese companies. At Sumitomo the representative said they developed their equipment and then waited ten years to see what would happen. He was trying to light a fire under them.

On my final visiting day, I stopped at several other booths relating to proton therapy, with which I am completely unfamiliar. One is Galaxy Proton Development Partners. According to their literature, they offer turnkey proton center installations, including feasibility studies, site selection, architectural and design services, and construction. They do not become a partner. The operation and success of the center is up to the operator However, they do own the physical plant and least it back to the client for twenty-five years. They allow the client to decide which brand of equipment to use.

Galaxy Proton Developers has an address in Winter Park, Florida. Shoot, I was just there a few weeks ago. I would have dropped by. The brochure gives no names for executives, no history, no credentials. On their website they appear to be quite substantial, with offices in Los Angeles, Atlanta, San Juan, Ulaan Baatar, London and Tel Aviv. Ulaan Baatar is in Mongolia. But then again, they could have one person sitting at a desk in each of those places, or some other company representing them. They also offer operational assistance, including staffing, marketing, and the like. They give no examples of a center which they built and own. That seems a bit strange to me. They claim to have contacts and connections in the proton world, but again, offer few facts or proof.

Next I visited pCure, which had a fairly large and expensive booth. The man I talked to was my age and said he goes back to before the development of Loma Linda in 1990. I asked if he knew Robert Wilson, the “father” of proton therapy. He said they had indeed met.

They describe their approach as “patient centric proton therapy.” They promise “enhanced clinical outcomes” by providing “the ability to offer proton therapy at a fraction of current capital and operating costs.” Their technology involves having the patient sit upright to receive treatment, rather than laying down, as when I was treated. They say their system is 20% of the size and half the cost of other equipment and can fit into one LINAC room. That’s it. No other technical information. Nothing about the making of the equipment.

When I asked if they had any operational example of their system, they said it was being developed at Northwestern University in Warrenville, Illinois. I pointed out that they already have a proton therapy center there. They gave a vague response indicating they were redesigning it. Later, when I looked up more information about that center, I found they have only one gantry and three fixed beam rooms. That is a very unusual configuration, and would fit in well with pCure’s technology.

I mentioned an article I had read, from Mass General, that said they could treat 70% of their patients using a fixed beam, thereby avoiding the costly three-story high gantry. The representative corrected me. “It is actually 100% using our technique.” I was left with the feeling that they have a product that could be advantageous, yet despite the major investment in their vendor space, they didn’t have many visitors, nor were they doing a very good job in presenting themselves. Their website says this:

Founded in early 2007, P-Cure, Ltd. has developed a comprehensive patient centric proton therapy solution with clinical benefits and financial advantages. P-Cure’s mission is to provide proton therapy with greater treatment precision, enhanced clinical outcomes, and expanded treatment options.
By significantly reducing the capital and operating costs, P-Cure expands the availability of proton therapy to all cancer care institutions and new facility developers worldwide.

When I think how hard it is to promote proton therapy in general, it must be an even greater challenge to introduce a new system within the proton therapy world. The IBA / Beaumont lecture on SPArc was about rotating the gantry for better accuracy, and here they are promoting having no gantry at all.

Lastly, i discovered TeamBest Medical companies. They make a big deal of the founder, Krishnan Suthanthiran and the various companies he has founded, such as Best Medical International, Best Cyclotron Systems, and Best Particle Therapy, all of which are Canadian companies. They make extravagant claims as to what they intend to do, including establishing a global network of 500 Cyclotrons (in the low 15 - 70 MeV range) and Radiopharmaceutical Clinics, open 24/7 and priced very reasonably. To treat most cancers, you need much more power, in the 200+ MeV range (Mev = a million electron volts).

But fear, not, they have great plans. They say they will develop their own unique 400 MeV Ion Rapid Cycling Medical Synchrotron with Variable Energy, Heavy Ion Treatment Technologies. These will include carbon which are heavier and perhaps even more accurate. To reach 400 MeV you need a synchrotron rather than a cyclotron. A cyclotron has a fixed energy output, which is then manipulated by using degraders and other attenuating devices. Synchrotrons, however, can control the energy level that they produce, hence the “variable energy.” They would also allow the possibility of proton tomography, the whole purpose for the company ProTom International, although the Best literature doesn’t seem to have adopted that possibility.

So, again, lots of fancy words, adequate resources, high visions. I certainly with them luck.
The rest of my discoveries came from the literature that I received at ASTRO, or as a result of the contacts and links that I gained. I couldn’t help but notice the presence of pharmaceutical giant IMFINZI, which advertises “The first and only approved immunotherapy” for unresectable lung cancer. (Unresectable means it can’t be addressed with surgery.) In the ASTRO daily publication, in which ads are quite expensive, IMFINZI had six pages describing their product.

One of the keynote speakers at the convention was Dr. Norman Sharpless, MD, director of the National Cancer Institute. I didn’t attend, not being registered for that, but read a summary. At the end of his talk he emphasized the future emphasis on immunotherapy and radiopharmaceuticals. In other words, drugs. Wouldn’t it have been good if he could have at least made a nod toward the potential of proton therapy?

Each year, at the ASTRO convention, they ask a particular question to which they seek responses. This year it was “What is the BIGGEST research discovery that needs to be translated to the clinic RIGHT NOW.” (The caps are theirs.) One would assume they are dedicated to technological advances. Yet they continue to resist proton therapy. I have more to say about that resistance, which I will put in a separate blog.

Dr. Brian D. Kavanaugh, MD, MPH, FASTRO, chairman of the board of directors, wrote an update in which he said this about treatment breakthroughs: “I am aware that prices of many new interventions are not sustainable, and there are imperfections in the way that new systemic therapies are evaluated and approved for marketing. Furthermore, not all cohorts of patients are yet benefiting from novel therapies.” That would seem to be a reference to proton therapy, except for the word “systemic.” Protons are just the opposite. They are specific and precise. Systemic refers to the pharmaceuticals again, indicating the stranglehold drugs have on our medical systems. Why? Because we have healthcare for profit in this country, in which we pay twice as much and receive less than any other industrialized country, all of which have some kind of universal healthcare.

Then, in writing about patient-centric indications, Dr. Kavanaugh says this. “We have always known about mucositis and pneumonitis and all of the other radiation-itises associated with therapy, and we try our best to mitigate them.” That’s a very revealing statement when you consider it is an admission of the very problem that confounds x-rays and is greatly eliminated with protons. The same article also covers the subject of “financial toxicity,” namely, the high cost of some treatments. To this he adds the importance of sexual health. He certainly seems to be skirting the edges of proton therapy. In his footnotes he suggests some articles to read to elaborate upon his comments. He praises the younger generation, hoping they will “disturb the universe” and question old dogma. It is as if he is right on the edge of praising protons, but just can't bring himself to do it.

In the literature rack ASTRO offered a series of pamphlets that cover the treatment options for a number of cancers: brain tumors, prostate cancer, breast cancer, etc. What do they say about protons? This is the sole paragraph in the eight-page brochure about brain tumors:
“Proton beam therapy delivers radiation therapy using particles instead of an x-ray beam. The benefit of proton therapy is that there is little or no radiation dose beyond the treatment area. This means that your doctor may be able to decrease dose to the surrounding healthy brain, which could lead tp fewer side effects during or after completion of radiotherapy. Proton therapy may also allow delivery of radiation a second time or a high dose of radiation for certain tumors involving the base of the skull. This treatment is not yet widely available throughout the United States. Ask your doctor if proton therapy might be beneficial for you.”

Do you see the subtle implication in using protons for failed treatments that need a second dose? This refers to failed x-ray therapy which needs to be treated, but is problematic because of the damage done during the original treatment. It is a bit of an admission that protons are beneficial in treating secondary cancers.

A positive observation is that the flyer doesn’t repeat the usual mantra that proton therapy is unproven, of lacking random studies, too costly, or no better than x-rays. Although the mention is brief, it is fair. Radiation therapy in general is described as “the careful use of high-energy x-rays or particles to safely and effectively treat brain tumors.” They did include particles, which is to say, protons.

Of course brain tumors are a place where most radiologists concede the superiority of proton therapy. What about prostate cancer? The brochure describes the process in some length including diagnosis and simulation 9the set-up for treatment). Then it says, “Intensity modulated radiation therapy (IMRT) and image guided radiation therapy (IGRT) are treatment approaches that allow the radiation beams to treat the cancer and lessen the risks of side effects.” (The bold was theirs.) Oops. Did we forget something here? Oh wait, look in the next paragraph: “In most cases, external radiation is in the form of high-energy photons, or x-rays. In a few clinics around the country, proton beam therapy is used to treat prostate cancer. Proton therapy is a form of external beam radiation therapy that uses protons rather than photons to treat cancer cells.” That’s it. It then goes on to describe brachytherapy, stereotactic body radiation therapy, and hormone therapy.

A whole page is dedicated to a list of potential side effects which may be controlled through medications or changes of diet. Hey, I know another way to control them. Use protons rather than X-rays. So here they give protons very little attention. Certainly. I thought to myself, they will give more protons more credit when it comes to breast cancer, as they greatly reduce or eliminate serious damage to lungs or the heart. That booklet talks about surgery and radiation after surgery. Then they say this: “Typically, radiation therapy is done with high-energy X-rays or photons.” That’s it. There is NO mention of proton therapy in the entire brochure. They go so far as to suggest that heart injury for left-side breast cancer is a ”very rare potential side effect.”

Breast cancer is a big money maker for radiologists and received a lot of attention at the expo. The failure to even mention the benefit of proton therapy conclusively demonstrates the primacy of profit over patient. This is criminal in my opinion. It violates the very foundation of medicine which says “first do no harm.”

Finally I looked at a brochure dedicated not to a specific cancer but to radiation therapy. It discusses radiation in general, except when it makes statements like this about external beam radiation therapy: “The treatment team uses a machine outside the body to direct radiation beams such as high-energy x-rays at the cancer.” Such as? Are there any other such as possibilities? At some length there follow descriptions of 3-D CRT, IMRT, IGRT, and stereotactic radiation, all forms of X-rays. Finally, they dedicate exactly two sentences to describing proton therapy. In the next paragraph they spend slightly more space describing neutron beam therapy, which it specifies is “available at only a few centers in the country.” That's it. Dilute the reference about protons by adding neutrons, as if both are equally obscure.

They downplay the side effects of X-rays, calling them temporary, mild, and treatable. First among them is fatigue. That is interesting, because if anything typifies my experience getting proton therapy for prostate cancer was how much energy I had. Besides my daily proton treatment, I was eating a proper diet, working out every day and sleeping well. I never had any indication of fatigue. Finally, they make this statement: “Long-term side effects of radiation therapy may occur in any normal tissues in the irradiated area. With careful radiation therapy planning using improved technologies, serious long-term side effects are uncommon.” They say that the possibility of developing a secondary cancer is extremely low. Except, I should point out, in, say, esophageal cancer, where it happens in about 96% of the cases according to a report by M. D. Anderson!

The brochures downplay side effects, yet spend some time mentioning them. Dr. Brian D. Kavanaugh, MD, MPH, FASTRO, chairman of the board of directors, wrote an article in the ASTRO newsletter. About patient-centric indications, he said this. “We have always known about mucositis and pneumonitis and all of the other radiation-itises associated with therapy, and we try our best to mitigate them.” The word "try" is key here. I think this is avery sensitive area when it comes to the superiority of proton therapy. One study they often refer to suggests that initially, protons do have fewer effects, but people recover in both instances, so after a period of time, the two modalities are equal. Nice try, but not the case.

So there you have it, a twenty-eight page brochure about radiation therapy that gives two sentences to proton therapy. ASTRO may give lip service to recognizing proton therapy, especially when vendors spend a fortune to promote their wares, but they are certainly throwing as many roadblocks in the way as possible. The main roadblock is their failure to refer patients for proton therapy. This is such a serious topic that I will write a separate blog about it.

There you have it. My expedition into the jungle of radiation therapy. I left the convention center and noted their sign above the entrance.

Outside, I found a vast selection of scooters, provided by three different companies to endanger San Antonio’s streets and sidewalks, not to mention the riders.

As I do at the end of all blog posts, let me invite you to check out my other related proton therpay sites:
This is dedicated to Robert Ferre's book Best Prostate Cancer Treatment: Proton Beam Therapy. It has updates and additional information, photos, and more.
This site has an up-to-date list of proton therapy centers in operation in the United States, as well as a number planned or under construction.