Department of Radiation Oncology, Cross Cancer Institute, and Department of Oncology, University of Alberta, Edmonton, AB.
Guideline Utilization Resource Unit, Alberta Health Services, Calgary, AB.
Curr Oncol. 2014 Oct;21(5):251-62. doi: 10.3747/co.21.2207.
Compared with photon therapy, proton-beam therapy (pbt) offers compelling advantages in physical dose distribution. Worldwide, gantry-based proton facilities are increasing in number, but no such facilities exist in Canada. To access pbt, Canadian patients must travel abroad for treatment at high cost. In the face of limited access, this report seeks to provide recommendations for the selection of patients most likely to benefit from pbt and suggests an out-of-country referral process.
The medline, embase, PubMed, and Cochrane databases were systematically searched for studies published between January 1990 and May 2014 that evaluated clinical outcomes after pbt. A draft report developed through a review of evidence was externally reviewed and then approved by the Alberta Health Services Cancer Care Proton Therapy Guidelines steering committee.
Proton therapy is often used to treat tumours close to radiosensitive tissues and to treat children at risk of developing significant late effects of radiation therapy (rt). In uncontrolled and retrospective studies, local control rates with pbt appear similar to, or in some cases higher than, photon rt. Randomized trials comparing equivalent doses of pbt and photon rt are not available.
Referral for pbt is recommended for patients who are being treated with curative intent and with an expectation for long-term survival, and who are able and willing to travel abroad to a proton facility. Commonly accepted indications for referral include chordoma and chondrosarcoma, intraocular melanoma, and solid tumours in children and adolescents who have the greatest risk for long-term sequelae. Current data do not provide sufficient evidence to recommend routine referral of patients with most head-and-neck, breast, lung, gastrointestinal tract, and pelvic cancers, including prostate cancer. It is recommended that all referrals be considered by a multidisciplinary team to select appropriate cases.
与光子放疗相比，质子束放疗（pbt）在物理剂量分布方面具有明显优势。目前，全球范围内基于旋转机架的质子设施数量不断增加，但加拿大却没有此类设施。为了获得 pbt，加拿大患者必须花费高昂的代价前往国外治疗。鉴于治疗途径有限，本报告旨在为选择最有可能从 pbt 中获益的患者提供建议，并提出了一种境外转诊流程。
系统检索了 1990 年 1 月至 2014 年 5 月期间发表的评估 pbt 后临床结果的研究，检索数据库包括 medline、embase、PubMed 和 Cochrane 数据库。通过对证据的审查制定了一份报告草案，然后由艾伯塔省卫生服务质子治疗指南指导委员会进行外部审查和批准。
质子治疗通常用于治疗靠近放射敏感器官的肿瘤，并用于治疗有发生放射治疗（rt）严重晚期效应风险的儿童。在非对照和回顾性研究中，pbt 的局部控制率似乎与光子 rt 相似，在某些情况下甚至更高。目前尚无比较 pbt 与光子 rt 等效剂量的随机试验。
建议对以治愈为目的、预计长期生存、有能力且愿意前往国外质子设施治疗的患者进行 pbt 转诊。目前公认的转诊指征包括脊索瘤和软骨肉瘤、眼内黑色素瘤以及儿童和青少年中存在长期后遗症风险的实体瘤。目前的数据没有提供足够的证据来推荐对大多数头颈部、乳腺、肺部、胃肠道和盆腔肿瘤（包括前列腺癌）患者常规转诊。建议由多学科团队对所有转诊进行评估，以选择合适的病例。
