The Proof Is in the Protons

Training for proton therapy gains ground

It’s a chicken-and-egg question for the modern age: How do you support the fastest-growing field in radiology when you’re trying to build the infrastructure that will finance, build, and power it at the same time?

The dilemma faced by ProCure Treatment Centers Inc., of Bloomington, Ind., is one most companies would love to have. But it’s also a trying circumstance. When you’re trying to hire, train, and employ the next generation of radiotherapists, medical physicists, and dosimetrists, sometimes on-the-job training doesn’t happen fast enough.

As is the case with most of its business model, ProCure is both establishing and exceeding the learning curve. It’s the dichotomy born of a field and a business model both seemingly in a constant state of flux. When you’re trying to engineer the advances in medicine that will push radiotherapy into the next technological age, you come to accept certain growing pains as the confluence of necessity, opportunity, and ambition.

The Control Group

Niek Schreuder, MSc, DAVR, is the senior vice president of medical physics and technology at ProCure. Although he’s not the literal architect of the new facility at the Bloomington campus, he is the person most responsible for seeing that all the pieces fit together.

The hybrid space serves multiple roles in the company’s business model, equal parts training school, tech bench, and support desk. The building itself also houses the research and development offices that will inspire and create the next generation of ProCure technology. Most importantly, however, it’s a clearinghouse of ideas that helps refine the delivery system for some of the most advanced radiotherapy treatment modalities available today.

But what will really make the ProCure Training and Development Center fully operational is an actual enrollment class.

“We haven’t had an official full class,” confesses Schreuder. “We’ve done some events with renowned Harvard physics professor, Bernard Gottschalk, but we are still currently developing the simulators. The full-blown program will launch in March ’09.”

Training for the class of March 2009 will coincide with the opening of the ProCure Therapy Center in Oklahoma City the following summer of the same year. Class sizes will incorporate various training modules that will instruct eight to 16 radiotherapists, dosimetrists, medical physicists, and physicians.

These modules will encompass proton development, management training, specific patient treatment modalities, and everything in between. Some of the education is based on distance learning and online-accessible models; some requires the in-person instruction that can only be obtained in the classroom.

But the most innovative function of the Training and Development center may be found on its lower level. There, you’ll find its bread-and-butter operation: the proton therapy simulators that replicate the exact conditions of the treatment room. To build these simulators requires what Schreuder describes as “a long lead time,” but they are designed to employ the “real” equipment in a life-sized training environment. The technology at work in the simulators lets students work hands-on while the patient is in the room, but without the complications of operating a live proton beam.

“If we had a patient in there, we could do a perfect placebo treatment in that room,” says Schreuder. “It’s really an exact treatment environment using the exact equipment, with the exception of the proton beam. It’s like driving the same model car in two different towns.”

“Behind the curtain,” Schreuder points out, the facility also allows ProCure to simulate the exact software environment used during the treatment process “so we have control over the workflow.” What he means is that ProCure can effectively modify its techniques and implement changes to them during the design process without operating in the kind of live environment that requires U.S. FDA-regulated safety guidance.

“We can get feedback about the best workflow on how to treat a patient,” says Schreuder. “And, since we’re not treating patients, we don’t need FDA approval to make any changes.”

“The way we view the training center is consistent with the way we view our position,” says John Henderson, ProCure’s chief operating officer, “as partners with others in the industry, trying to make protons more available to patients. We want to be able to create access to protons for patients and we want to be able to do it faster. In some respects, we hope we’re setting an interesting example for others.”

“For us, it’s kind of a win-win situation,” echoes Schreuder. “When we started off, there wasn’t strong competition. We were at the right place at the right time to get things off the ground. Now, we have a significant differentiator that we can exploit for the benefit of our patients.”

Faster Ramp-Up Equals Broader Acceptance

As Schreuder says, “the only problem with proton therapy is the lack of proton therapy.” What he means is there’s a relatively long lead time required to adopt anything new and different from the established treatment schemes.

“Anything in the minority, people question why it’s not being used,” Schreuder says.
That’s why the faster the company can bring its facility online, the more money it will recoup on its investment. Full usage of the space they’re already sinking their dollars into would create “a tremendous increase in revenue,” Schreuder says. That means the company would be well on its way to making back costs put into training and professional development. It also means a faster roll-out of patient services, and a significant edge over potential rivals preparing to enter the proton game.

“ProCure hopes that we could start constructing two of these facilities per year,” says Schreuder. “You cannot show clinical results if you’re only treating 5,000 patients a year. Compare that with the 850,000 patients being treated with X-rays. Five years from now, we should be close to 10 facilities operational in the U.S.”

In four to five years, Schreuder estimates, there will be twice the capacity for proton treatment. That means that the proof of concept in its business model will allow the company to demonstrate greater clinical results, thus also driving greater acceptance of proton therapy as a treatment for various diseases. It doesn’t mean, however, that he foresees proton therapy as a replacement for existing modalities – rather, he views it as a complementary treatment.

“Whatever ProCure is doing, we try to remind the doctors that proton therapy is a supplemental tool,” says Schreuder. “It is not a replacement for the other therapies. There are huge industries behind X-ray, for example, and thousands of people behind it. What ProCure is working to do is make our technologies compatible with what’s going on right now. It’s really just another tool.”

The Forerunners

Schreuder is fond of the term “before-the-job training.”

“We cannot do ‘on-the-job-training,’ because these facilities are very expensive,” he says, citing a loss of revenue, danger to the patient, and various other obstacles. Schreuder refers to the professionals to be trained by ProCure as “reconditioned” experts, who will boast a foundational familiarity with various other forms of radiotherapy.

“All new therapists coming out of the training school have to do experiential training, shadowing experienced therapists before they can push the start button on the patient,” Schreuder says. “We’re just changing the equipment.”

For Larry Swafford, PhD, RT, of Ivy Tech Community College in Bloomington, Ind., the center represents quite a broader opportunity. As program director for the radiation therapy program, Swafford is taking advantage of the lab space made available to his charges through an agreement with ProCure. With a lack of incoming students, Schreuder’s group has implemented a conventional radiation therapy training simulator for use in traditional programs. What he sees at ProCure is a unique opportunity for his students that couldn’t exist in any other setting.

“There’s no certification that exists for proton therapy right now,” Swafford says. “We have the world’s first training center with fully functioning equipment. Anyone who wants to be trained specifically in protons has the opportunity to come here and do that. I’ve had calls from all over the country, from Ireland, to Australia. The word is out.”

With more centers like Bloomington on the way in the next five years, companies like ProCure aren’t just driving demand – they’re driving the market. Swafford hopes to start offering the education that will make his students market-ready on a similar timeline with that of ProCure and its hirelings.

“Every major city in this country is probably going to want a proton center: St. Louis, Columbus, Seattle,” says Swafford. “We’re at the very front end of this field that is probably going to steamroll here in the next few years. So we might as well develop a program that those radiation therapists can come, get their training, and go to work wherever the next center opens up.”

Through didactic distance learning and in-person lab practicums, Swafford’s independent facility can even offer clinical experience through the much larger and older Midwest Proton Radiotherapy Institute (MPRI) – also located in Bloomington. The entire process may last as long as 12 weeks for people in need of the clinical experience Swafford’s connections can offer, but it provides a natural synchronicity born of the interconnections in this one-of-a-kind town.

“Many of the people who work for ProCure came from MPRI,” Swafford says. “As ProCure found their footing, the program affiliated with them as well.”

He adds, “We can graduate those students and offer the opportunity for other people to come to Bloomington to train in Proton Therapy.”

ProCure, MPRI, and Ivy Tech are jointly working on a certificate program for proton therapy that will fill a need currently unmet in the field while drawing from the same talent pool from which ProCure someday expects to fill its ranks.

“What we’ve decided to do is look at the other programs that the [American Registry of Radiologic Technologists] has,” Swafford says. “We’re looking at how they’re structured – the goals for the curriculum and the registry and so forth – the way you would expect the societies would want one so the students could sit for a national specialty exam.”

Swafford has served as a site visitor for the Joint Review Committee on Education in Radiologic Technology (JRCERT) for many years. This background has informed the academic standard to which he holds the joint program between IvyTech and ProCure. It’s his hope to anticipate the rigors of JRCERT certification, a tricky thing to do when no such set of guidelines exists for proton therapy.
 
“We’re trying to anticipate that, so that when proton therapy becomes common enough to implement standards, we’re right there,” Swafford says. “We’re developing the program from scratch because nothing in the world like this exists. I’m in the unique position that ProCure built this training and development center here in Bloomington, Indiana, and there is no other one.”

“It’s expensive,” says Schreuder. “We’re probably about $10 million into the training run, but you can’t compromise on quality. There’s no substitute for trained staff.”


His Light Materials

Bernie Gottschalk, PhD, is 73. Currently, he is unaffiliated with any institution or organization, although he enjoys the privileges that his stature at Cambridge, Mass.-based Harvard University affords him – namely, his own office, with an Internet connection and the ability to work unmolested in one of the pre-eminent research universities of the world.

Trained as a nuclear physicist, Gottschalk cites his “midlife crisis” as the inspiration for his shift from high-energy, experimental physics to joining the Harvard Cyclotron project for 23 years until it was shuttered in 2002. In his time there, he consulted for IBA, the single largest supplier of proton therapy equipment in the world, and a forebearer of ProCure. Their prototype installation in Boston’s Massachusetts General Hospital gave Gottschalk the inspiration to pursue his work in proton therapy.

“I thought for a while, ‘What could I most usefully do during my retirement?’” says Gottschalk, “and at the time it was already obvious that proton therapy was going to take off. It’s not a mass business, but it is an interesting business, considering that each of these things costs somewhere between $50 to $100 million.”

In foreseeing the advancement of the field of proton therapy, Gottschalk, an old friend of Schreuder’s, also saw something of a shortfall in the science necessary for those who will operate within it. A member of the Proton Therapy Cooperative Group (PT-COG), which describes itself as “an organization for those interested in proton, light ion, and heavy charged particle radiotherapy,” Gottschalk had given a series of lectures on the intermediate physics related to proton therapy but which may be missing from the normal college curriculum.

“This is a kind of physics that is not highly advanced – sort of the level of an advanced undergraduate or beginning graduate course – and for that very reason it’s not taught anywhere,” Gottschalk says. “You can’t find a physics department that teaches this stuff, but there’s a whole branch of people who need to know it, and I thought I could put together a course and teach it. That’s basically what I’ve done.”

Gottschalk collected his thoughts in the form of a lecture series, a book draft, and a few videotaped classroom sessions. He recognized that the ProCure facility was designed basically for the training of therapists, but could also meet the needs of physicists at the same time. In the span of a week, he found he could offer all the education physicists would need to take the next step in their educations.

“It’s really just a lecture course,” Gottschalk says, “but many of the manufacturers can’t afford to do it because they’re trying to keep their heads above water. Some of the people there might never use this stuff, and others might use it quite a bit. You might only know that 20 years later. It’s essentially continuing education.”

Thus, Gottschalk and Schreuder formed the course Schreuder bills as “Basic Physics Techniques in Proton Therapy,” which covers what Schreuder describes as “the hardcore, fundamental physics of how proton therapy works,” from the use of accelerated particles to the physics of dose calculations, distribution, and beam spread on patients.

“Whatever we do, we try to improve the people’s professional careers,” Schreuder says. “We have our own unique configuration of the equipment that not too many other facilities at this point have. The more questions you get, that feeds back logically into what you should be including in your training.”

“I spent about 25 years learning this stuff, and it would be nice if people just entering the field also didn’t have to spend 25 years learning it,” Gottschalk jokes. “Our director, Andy Kohler, at the Harvard Cyclotron, really believed in giving people time to develop themselves. That was enormously productive. If you’re hired on as a medical physicist at a therapy center, such people are far too busy with everyday tasks to do much in the way of research. At Harvard, I really had the opportunity to think about problems, and I think what I’m doing is a little bit of paying back for that opportunity.”

A Nexus of Industrial Development

At its best, Henderson believes ProCure’s new Training and Development Center has the magical chemistry of the right piece of innovation in the right location and at the exact right time.

“It’s the place where ideas are coming from,” Henderson says. “It feeds itself, and it’s really a whole nexus of development for the industry. It’s a very active process. Even with so many new people coming in, there’s still that level of collegiality, excitement, and engagement.”

Henderson believes that the natural energy and excitement of that one-of-a-kind happenstance attracts a certain kind of individual who is best situated to work in the field his company is helping to create.

“The most fundamental element of everybody who comes into this organization is the feeling that they can actually make a difference to other people,” he says. “That fiber of the company naturally lives within what we do in training, the way we teach our courses, the way we think about how we’re going to train people. I think it’s harder to say ‘I’m going to build coursework around it,’ but that lives within the very people who come to ProCure. It’s what attracts them here, and what gives energy to the work they do here.”

— Matt Skoufalos is a New Jersey-based freelancer. Questions and comments can be directed to editorial@rt-image.com.