This article is not about fake news. Nor is it about bad news. It’s not even about good news.
This article is about no news, which contrary to popular belief, is not always good news.
When proton therapy is entirely left out of a discussion about radiotherapy for treating cancer—especially prostate cancer—my blood boils. When people use the term “radiation” with the unstated assumption that there is only one kind—the conventional type, the traditional approach, “regular” radiation—I want to tear my hair out.
As you might already detect, this article is a bit of a rant, triggered by a couple articles I recently read and will discuss here. It’s a rant about failures to mention proton therapy at blatantly appropriate opportunities. It’s about allowing proton therapy to completely lose its identity by burying it within the broader term, “radiation.”
… the resulting tragedy is that patients unaware of proton therapy cannot even consider its remarkable benefits.
We proton ambassadors fume when negative and inaccurate comments are made about it, and so we should. But the bigger problem is that publications and medical professionals usually say nothing at all, as if PBT were non-existent. This makes proton therapy invisible to most people. And the resulting tragedy is that patients unaware of proton therapy cannot even consider its remarkable benefits.
Love me, hate me, but please don’t ignore me
Astonishingly, even after more than a quarter century of successful use in the treatment of cancer, proton beam therapy still suffers from a severe identity crisis. Despite its accelerating proliferation, it may well be the best kept secret for cancer therapy. Why? Among other reasons, PBT remains a victim of rampant errors of omission.
It would be great if more people in the media and medical community praised proton therapy’s unique benefits at every opportunity, but this is relatively rare. The next best scenario, albeit a distant and counter-intuitive second choice, would be mentioning PBT in a negative context. This occurs mostly in fake news, editorials disguised as news, and blatantly biased reporting—all also relatively rare. Relative to what?
Far more often than being praised or panned, proton beam therapy is not acknowledged at all.
More prevalent and far worse than good news or even bad news is no news. The silent treatment. Lack of any mention whatsoever results in invisibility. Tragically, this remains the current plight of proton therapy. Far more often than being praised or panned, proton beam therapy is not acknowledged at all. Not by the media, not by medical publications, and not by doctors—most notably urologists.
It’s as if it doesn’t even exist. Here are two recent examples:
Proton beam therapy IS radiation
Even when radiation therapy is the topic, proton is absent from the discussion. As just one of many examples, consider this article from the Prostate Cancer Foundation. In the context of discussing radiation for prostate cancer it purports to answer the question, “What is Radiation Therapy?” Clearly proton therapy, along with conventional radiation and brachytherapy, should be part of the discussion.
… this definition would have earned a failing grade simply because you cannot define “radiation” by using the word “radiation.”
The article begins with this definition: “Radiation is the strategic use of ionizing radiation or photons to kill cancer cells.” In my high school English class this definition would have earned a failing grade simply because you cannot define “radiation” by using the word “radiation.” Radiation is radiation is radiation. But let’s set the circular aspect of their definition aside and consider how a typical reader might interpret it as stated.
It all depends on how you read the “or.” Is ionizing radiation the alternative to photons? Or is it the equivalent, as in dried grapes or raisins? The latter could easily be understood to make radiation synonymous with conventional photon (x-ray) radiation, when in fact ionizing radiation is a broad category including photons, protons, and more. The “or photons” part of the definition is unnecessary, misleading, and confusing at best, and it helps bury protons even further into obscurity.
PBT is EBRT … or is it?
The second section of the Foundation’s article describes External Beam Radiation (EBRT). Giving me false hope of at least an honorable mention for PBT it correctly begins, “There are many types of EBRT, each with its own advantages and disadvantages.” But proton’s not even mentioned. A squandered opportunity to describe how the Bragg Peak phenomenon allows proton therapy to spare healthy tissue.
PBT, unquestionably a unique form of EBRT, was not mentioned even in passing. After all, radiation is radiation.
Could it be in their linked article specifically focusing on EBRT? Nope. Not there, either. Each of 3DCRT, IMRT, and IGRT has a bold heading and a lengthy paragraph. But PBT, unquestionably a unique form of EBRT, was not mentioned even in passing. After all, radiation is radiation.
Next, three categories of treatment duration for EBRT are explained. Conventional, moderate-hypofractionation, and ultra-hypofractionation (stereotactic body radiation therapy, SBRT) are described nicely. It appears to be sufficiently detailed and definitive, but again there’s no mention of proton therapy, which is delivered in all durations.
Searching in vain
Photons, EBRT, brachytherapy, LDR, HDR, hormones … it’s all there. Surely the Foundation will devote equal time to protons somewhere. They ignore PBT in the main article and even in the linked one on EBRT, so I set out to find where they do discuss proton therapy.
Upon entering “proton” as my search term I was offered links to pages containing “prolong,” “protocol,” and “photons.” Not proton.
Still hopeful, I used their own search tool at the top of the Prostate Cancer Foundation Page. Upon entering “proton” as my search term I was offered links to pages containing “prolong,” “protocol,” and “photons.” Not proton. Apparently “proton” does not exist anywhere on this entire website.
In contrast, type “photon” as a search term and the first entry is “… use of ionizing radiation or photons to kill cancer cells …” Likewise, “seeds,” “brachytherapy,” and “EBRT” all hit the bullseye for relevant articles. Only “proton” has no target to hit on this website.
Another error of omission
The Prostate Cancer Foundation’s website is merely one example of failure to provide complete information to patients, and they have a lot of company. I’ll give you just one more example, the one that inspired this blog post. The article published on the UroToday website is called “ESOU 2019: Modern Radiotherapy for Prostate Cancer Treatment,” presented by Dr. De Meerlander, a radiation oncologist.
The second paragraph gave me hope that someone else was finally going to acknowledge the identity crisis facing proton therapy. With laser-like focus on the issue at hand, he begins, “Unfortunately, when radiotherapy is discussed for prostate cancer, it is all lumped together in one general category ‘radiotherapy.’ ” Yes! That is spot-on and most unfortunate, especially for PBT. I believe this “lumping together” is one of protons biggest identity problems.
The differences between proton and conventional photon (x-ray) radiation are not widely understood, mostly because few sources discuss PBT at all.
He correctly continues, “… there are drastic differences in the radiotherapy given …” Yes! Let’s talk about that! The differences between proton and conventional photon (x-ray) radiation are not widely understood, mostly because few sources discuss PBT at all. So now, I expected, a credible unbiased source will finally highlight how proton therapy is different. But that was not part of the discussion. The word “proton” does not appear even once.
An incomplete conclusion
Dr. De Meerlander’s wrap-up is accurate, but incomplete. He reminds us that in order to make appropriate comparisons “when talking about RT” we must “always know the radiation dose, the schedule and the specifics of the modality.” Well, shouldn’t those specifics have included some mention of the remarkably unique and beneficial characteristics of proton therapy?
His final words are, “Radiotherapy for the prostate is rapidly changing!” And he’s right. Too bad he omitted one of the most remarkable innovations in radiotherapy. Maybe someone should remind him to remind others that proton therapy is cutting-edge radiotherapy, and it is leading the way.
To be sure, both articles I mentioned here are useful and informative. They’re not fake news, biased reporting, or editorializing. I presume that their authors are dedicated with only pure motives. The sad truth is that they, like most of the population, probably do not think of proton therapy at all, not even in the specific context of radiation therapy for cancer. It just doesn’t occur to them, so of course they don’t mention it.
No news is even worse than bad news for spreading the word about proton therapy.
Maybe silence is sometimes golden. No news might be good news. But I stand by my earlier statement: No news is even worse than bad news for spreading the word about proton therapy.
I realize I may be preaching to the choir, and that’s fine. I hope this rant will remind and inspire you, the choir of proton ambassadors, to sing loudly about the benefits of proton therapy whenever you can. Proton therapy is not the solution for every cancer patient, but each patient deserves to know it exists. If we don’t break the silence surrounding proton therapy, who will?
“… no one dare disturb the sound of silence.” — Paul Simon
Is no news worse than bad news? Email me here!