By Theresa Edwards Makrush
Edited by Michael Rutenberg, MD, PhD, UF assistant professor of radiation oncology

The esophagus, part of the digestive or gastrointestinal system, carries food and liquids from the mouth to the stomach. According to the National Cancer Institute and the American Cancer Society, most signs and symptoms of esophageal cancer occur when the disease is at a later stage and the cancer is more difficult to treat. Difficult or painful swallowing or worsening reflux symptoms are the most common symptoms of esophageal cancer symptoms, though they are also common symptoms of other benign diseases. Tests such as CT or PET scans, blood tests, endoscopy and biopsy are used to confirm and stage an esophageal cancer diagnosis.

Treatments often include chemotherapy, radiotherapy, and surgery. For many esophageal cancers, combined therapy (e.g., chemoradiation and surgery or chemotherapy and radiation) provides the best treatment. Proton therapy is an advanced form of radiotherapy that can deliver targeted radiation to the treatment area and minimize harm to surrounding healthy tissue. Because the esophagus is located adjacent to critical organs like the lungs and the heart, proton radiotherapy is ideally suited to deliver curative radiation to the cancer while reducing the dose to the heart and lungs.

Treatment planning studies and early patient outcomes reported by academic proton centers show very promising results with proton therapy in combination with chemotherapy. Among the advantages include reduced treatment related complications including reduced inflammation of the lungs (pneumonitis) and reduced damage to the heart. Reducing the impact of curative treatment on normal, healthy lungs and heart tissue may significantly improve the quality of life and long-term survival of esophageal cancer patients.

1. Prayongrat A, Xu C, Li H, Lin SH. Clinical outcomes of intensity modulated proton therapy and concurrent chemotherapy in esophageal carcinoma: a single institutional experience. Advances in Radiation Oncology. 2017;2(3):301-307.

2. Xi M, Xu C, Liao Z, Chang JY. Comparative Outcomes After Definitive Chemoradiotherapy Using Proton Beam Therapy Versus Intensity Modulated Radiation Therapy for Esophageal Cancer: A Retrospective, Single-Institutional Analysis. International Journal of Radiation Oncology Biology Physics. 2017;99(3):667-676

The Artists-in-Medicine duo Barbara Fryefield Holmes and Pamela Gardener led patients in an exploration of the sun – its energy, warmth, and uplifting joy. The resulting artworks are currently on display in the patient luncheon room. Methods used to create the expressions of sunshine include wax resistance, acrylic painting, mono-printing and collage.

A few selections from the exhibit are shown below.

By Theresa Edwards Makrush

When patients complete their course of proton therapy at the UF Health Proton Therapy Institute, they ring Aud’s Chime in The Players Lobby. Often their friends and family are there to help celebrate the moment along with fellow patients and caregivers. Applause, hugs, and smiles always accompany the sound of the chime.

A recent “graduate,” as patients who complete treatment are called, had an extraordinary group assembled for his chime-ringing day. Brian Kernohan, a lieutenant with 15 years of experience at the Jacksonville Fire and Rescue Department, was surrounded by an estimated 100 fellow firefighters and first responders. News crews from three local TV stations were there to capture the remarkable scene. (See news stories at news4jax, actionnewsjax and firstcoastnews.)

The outpouring of support was overwhelming, said Brian’s wife Katie. “I don’t know of any other company that is this supportive. We are grateful and overjoyed,” she said. “We love everyone here. They are such an encouragement.”

Brian said that two weeks before Thanksgiving he was suffering from intense head pain and went to the emergency room at a local hospital. After receiving the results of an MRI less than 24 hours later, the 36-year-old was told he needed surgery to remove a rare medulloblastoma brain tumor that is more typical in children under the age of 10. Following a successful surgery, Brian had 30 proton therapy sessions to target radiation in the area where the tumor was removed as part of a treatment plan that may also include chemotherapy.

According to Brian, having a positive attitude has helped him cope with treatment, along with the support of his family members and coworkers he thinks of as family. “My brothers really stepped up today,” he said as he looked out at the smiling faces lining the spiral staircase from top to bottom.

By Bradford S. Hoppe, MD

The standard-of-care treatment for patients with locally-advanced, non-small cell lung cancer, or Stage 3 NSCLC, is concurrent chemotherapy and radiation therapy, including proton therapy, as a potentially less-toxic, yet effective, treatment option. Clinical trials for Stage 3 NSCLC are open at the UF Health Proton Therapy Institute examining 1) hypofractionated (an accelerated course of proton treatments delivered over 3 weeks instead of 7 weeks) proton therapy with chemotherapy and; 2) proton therapy versus X-ray radiation. Unfortunately, these clinical trials have been difficult to accrue patients. Two new studies published by UF explored these issues surrounding the accrual.

In the first study, the researchers demonstrated the main barrier for enrolling patients into clinical trials was patient ineligibility, due to several medical issues making them “unfavorable,” including previous lung cancer surgery, poor lung function, weight loss, prior cancers, and other medical comorbidities. Additionally, it was shown that patients getting proton therapy for Stage 3 NSCLC at UF are older than typical Stage 3 NSCLC patients. This finding is likely due to older patients having Medicare, which covers proton therapy for lung cancer, while many private payers are not covering treatment cost—even on clinical trials.

The second study by the UF researchers looked at the outcomes of 90 consecutive patients treated with proton therapy at the UF Health Proton Therapy Institute.

The two-year Stage 3 NSCLC patient outcomes, published last month in Acta Oncologica, [1] suggest that favorable- and unfavorable-risk patients responded similarly to proton therapy. Patients were categorized as favorable-risk, people who had no other health issues, or unfavorable-risk, people who had one or more of the following risk factors:

• age ≥ 80
• stage IV cancer
• weight loss >10% in 3 months
• performance status ≥2
• FEV1 <1.0 or oxygen dependency
• prior lung cancer
• prior lung surgery
• prior 2^nd cancer in the past 3 years
• prior chest irradiation

After two years, the overall survival was 52% and 45% for favorable- and unfavorable-risk patients, respectively. Overall survival measures the percentage of people in the study who are still alive. “Most patients treated with proton therapy for Stage 3 NSCLC have unfavorable risk factors. These patients had similar outcomes to favorable-risk patients,” said researchers. “Enrollment in future clinical trials may improve if eligibility is less restrictive.”

In fact, these study results have led to a re-evaluation of clinical trials eligibility requirements and broadened them for patients with Stage 3 NSCLC.

[1] He J. Zhu, Romaine C. Nichols, Randal H. Henderson, Christopher G. Morris, Stella Flampouri, Dat C. Pham, Christopher L. Klassen, Vandana Seeram, James D. Cury, Lisa Jones, Lisa McGee & Bradford S. Hoppe (2019) Impact of unfavorable factors on outcomes among inoperable stage II-IV Nonsmall cell lung cancer patients treated with proton therapy, Acta Oncologica, DOI: 10.1080/0284186X.2018.1546060