The Beam: Understanding liver, gastrointestinal and breast cancer treatments at Fred Hutch – Proton Therapy

Hepatocellular carcinoma (liver cancer): treatments and updates explained

The liver is an extremely sensitive organ. It filters blood, eliminates toxins and creates bile to digest food; without a functioning liver, a person will die.

Its sensitive nature, however, makes it hard to treat when something goes wrong such as cirrhosis or cancer.

The most common type of liver cancer is called hepatocellular carcinoma, or HCC. Among gastrointestinal (GI) cancers in the U.S., HCC is rare, but worldwide it’s one of the most common — and one of the deadliest.

HCC is caused by cirrhosis of the liver, which can be the result of infection with hepatitis B or C virus, alcohol consumption or as a result of long-standing obesity (fatty liver disease). In much of the world, hepatitis has not been controlled through vaccines as it has been here in the U.S.

Patients with HCC usually don’t experience symptoms until it’s advanced. Because there are known risk factors, patients who have hepatitis, cirrhosis or have had liver cancer before can be screened for HCC with a yearly ultrasound.

“Because of the underlying bad health of the liver when we treat liver cancer, stakes are high,” said Smith Apisarnthanarax, MD, a Fred Hutch radiation oncologist who specializes in GI cancers, especially liver cancers. “Further damage to the liver can severely affect the patient’s life.”

The primary treatment for liver cancer is often surgery (or transplant) or thermal ablation, which uses microwaves. There are also catheter-based therapies that funnel radiation or immunotherapy beads through a tube directly to the blood vessels feeding a tumor. And there is radiation, including proton therapy.

“In the world of proton therapy, liver cancer — especially large tumors — is one of the disease areas where most providers agree it’s an important treatment tool,” Apisarnthanarax said. “That’s because the larger the tumor, the higher the dose we need to control it, and that increases the risk to the sensitive healthy tissue. So, for cases when the tumor is the size of a grape or larger or when a patient has had prior radiation, among other scenarios, I like to recommend proton therapy.”

Apisarnthanarax treats about 20 HCC patients a year using protons. He and his team are about to publish the results of an institutional chart review that studied how effective proton therapy was for patients with large tumors since 2014. It will be the largest study of its type in the U.S. to date.

“We found that even for very large tumors — the size of a grapefruit for example — proton therapy is effective in controlling the tumor in close to 90% of cases,” Apisarnthanarax said. “We saw reduced liver toxicity in patients with overall healthier livers, too.”

Controlling the tumor means it’s been effectively eliminated and won’t come back. But unless a patient receives a transplant, the risk of developing a different tumor outside the treatment area is still about 50%, because of underlying disease in the liver such as cirrhosis.

Apisarnthanarax is also about to publish a study documenting his team’s use of liver function imaging in treatment planning for both proton and photon radiation therapy – research he and the team pioneered at Fred Hutch. Using a tool called Colloid SPECT/CT imaging, they can map out the liver in 3D to better understand which parts are healthy and which are damaged.

“This allows us to create better treatment plans and increase safety,” Apisarnthanarax said. “It’s pretty exciting to be at the forefront of this.”

To learn more about proton therapy for liver cancers, visit the Fred Hutch GI cancers webpage. 

Fred Hutch specializes in treating gastrointestinal cancers, which are on the rise in younger people

There have been many stories about the rise in colorectal cancer in people under 50, but that increase is not limited to colorectal cancer. There is evidence of a rise in other gastrointestinal (GI) cancers in young people, as well. In fact, early-onset GI cancers represent the most rapidly increasing early-onset cancers in the U.S.

GI cancers include colon, rectal and anal cancers, as well as esophageal, gastric (stomach), bile duct and pancreatic cancers, among others.

It’s unclear what exactly what’s triggering them, but there seems to be a strong link to environmental and lifestyle factors, including the rise in obesity rates and factors such as a diet high in red meats and processed foods.

“It’s believed that heavy ingestion of certain foods and other substances such as microplastics increase inflammation in the body and upset the body’s microbiome, both of which can be drivers for cancer development,” said Fred Hutch GI medical oncologist, Stacey Cohen, MD. “GI cancer risks are decreased in subjects who adhere to a diet rich in whole grains and nuts and who minimize the amount of red meat and sugar-sweetened beverages, especially when paired with a more active lifestyle.”

A recent study published in the Journal of the American Medical Association found that “patients with early-onset GI cancers typically receive more treatments but often have similar or shorter survival,” suggesting that cancers that develop in younger individuals are more aggressive and less responsive to standard treatments.

Fred Hutch, the only cancer treatment facility in the state with the National Cancer Institute Comprehensive Cancer Center designation, has experts in GI cancers including gastroenterologists, medical oncologists, radiation oncologists and surgeons who focus exclusively on treating GI cancers.

In addition to offering the latest and best treatments, including chemotherapy regimens that are easier to tolerate and surgical procedures that are less invasive, Fred Hutch is the only center in the region that can offer proton therapy. Proton therapy better protects surrounding healthy tissue from the negative effects of radiation, according to Smith Apisarnthanarax, MD, one of Fred Hutch’s radiation oncologists specializing in GI cancers.

Proton therapy can be especially helpful for patients who need radiation treatment in an area that has already had radiation.

The beams are precisely controlled to target the tumor while delivering less radiation to nearby healthy tissue, crucial since nearby tissues may have already been affected by past treatment. Proton therapy also allows us to treat recurrent (tumors that have come back) or new tumors in sensitive areas more safely. It gives patients a safe and effective alternative to traditional radiation. Since every cancer is unique, providers at Fred Hutch can offer guidance in understanding the nuances of when proton radiation is the best option.   

Many GI cancers benefit from proton therapy, including the following:

Esophageal Cancer

Located in front of the spine, behind the heart and between the left and right lungs, the esophagus is in a hard location to treat, both for surgery and for radiation. Proton radiation for esophageal cancer can help reduce radiation to healthy tissue, and studies show that it may lead to fewer side effects from radiation treatment.    

Liver Cancer

Radiation therapy is an important treatment option for liver cancer patients, but the liver is a delicate organ that can be damaged by treatment, especially in those who already have liver problems. Proton therapy’s targeted nature helps protect healthy liver tissue while sending an effective dose of radiation directly to the tumor. By minimizing damage to the rest of the liver, proton therapy can reduce side effects and make treatment safer.

Pancreatic and Bile Duct Cancers

For patients who have pancreatic cancer only in their pancreas, or people who have recently had surgery to remove their pancreatic cancer, proton therapy may be an effective treatment because it can reduce the radiation dose to kidneys, liver, spinal cord and bowels. This may lower the risk of side effects like nausea, vomiting and diarrhea. 

Rectal and Anal Cancers

Radiation therapy is an important part of treatment for patients with rectal and anal cancers. These cancers are located near healthy tissue like the small and large intestines, bladder, bone marrow and reproductive organs. Proton therapy may lower radiation exposure to these nearby organs and help reduce side effects like diarrhea, urinary problems, abnormal blood counts and sexual dysfunction. 

Studies have shown that patients evaluated and treated at a multidisciplinary cancer center like Fred Hutch, where specialists work in concert to develop optimal treatment plans for all patients, have better outcomes.

In addition, research shows that where a patient has their first cancer treatment makes a difference. Research and cancer care go hand in hand at Fred Hutch; finding and developing the best treatments is what sets Fred Hutch apart in terms of the best cancer outcomes.

For more information, visit the proton therapy GI cancers website and use this form to contact us about treatment. 

Proton therapy: an important tool in treating breast cancer, especially in the left breast

It’s been well-established that exposure of the heart to radiation increases the risk of developing radiation-induced heart disease, a late complication that can occur after radiation therapy is delivered to the chest area for cancer treatment.

Radiation can cause fibrosis in any part of the heart within the treatment field and increase the risk of serious heart problems down the road.

Higher doses to the heart can lead to greater risk, which may be of particular concern for breast cancer, where the heart lies in close proximity to the area being treated.

Because the heart lies towards the left side of the chest cavity, radiation treatment for breast cancer in the left breast (or to the internal mammary lymph nodes, or IMN, in the center of the chest), poses a higher risk of radiation exposure to the heart than treatment for cancer in the right breast.

When physicians at Fred Hutch need to treat a tumor in the left breast or target lymph nodes in the center of the chest, they often work with dosimetrists to create a treatment plan using proton therapy.

“When a charged particle such as a proton moves through the body, it deposits a small dose of radiation along its path,” said Bao-Ngoc Thi Nguyen, CMD, dosimetry manager at Fred Hutch – Proton Therapy. “A peak of radiation deposit occurs right before the proton loses all energy and is no longer radioactive.” “Dosimetrists calculate exactly where they want this peak to occur within the tumor. Because there is [minimal] dose beyond the target, beams of proton therapy can be angled to avoid hitting the heart better than plans using photon radiation [X-rays], which lose energy gradually and can’t be targeted to stop at a certain point.”

In order to decrease the risk of side effects using traditional photon-based radiation, doses delivered to the breast, chest wall and lymph nodes sometimes have to be reduced, or there may be greater spill-over of lower radiation doses into the surrounding normal structures, which can result in less optimal disease control.

It can also result in increased side effects or even secondary malignancy risk. 

 “We strive to ensure that any radiation plan we create does minimal damage to the healthy surrounding tissue,” said Kylie Kang, MD, who treats breast cancer using many types of radiation at Fred Hutch. “Thankfully, we have many radiation options available to our patients at Fred Hutch, including being the only place in the Pacific Northwest to currently offer proton therapy.”

Protons are often useful in treating:

• Node-positive breast cancer: even when the cancer is primarily in the right breast, if lymph nodes are involved, especially in the IMNs, protons can be helpful in minimizing radiation to healthy tissue.
• Locoregionally recurrent breast cancer/patients who have had radiation to the chest area in the past: each patient can receive only a certain lifetime dose of radiation to the same healthy tissue. Proton therapy can help minimize overlap in the areas of one’s body that have received radiation dose in the past and thus permit re-irradiation.

There are more treatment options today than ever before to control breast cancer, even for patients with metastatic disease (stage 4 or advanced cancer that’s spread to a distant part of the body). Radiation is often part of the suite of options that work together to treat the disease. For instance, it’s not uncommon to use radiation after surgery to help reduce the chance that non-metastatic breast cancer will recur.

Fred Hutch radiation oncologists review each case with a team of other breast specialists including medical oncologists and breast and plastic surgeons, with the goal of crafting a treatment plan that is specialized to each patient's diagnosis and needs."

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