Oncology nurse helps kids avoid anesthesia

Mentoring program created by oncology nurse to help young patients avoid anesthesia during treatment

In August 2010, Bolton developed a mentoring program to help children avoid anesthesia during proton therapy. Generally speaking, children up to age 7 receive anesthesia to ensure immobility during treatment. However, sometimes it is apparent at the initial consult that some children between the ages of 6 and 7 may be able to proceed through the treatment without anesthesia. If this is the case, the mentoring program is discussed with the parents and the child. Bolton mentored the first child in the program, who was able to receive treatment without anesthesia. Children who choose to participate in the mentoring program will meet with a child who is currently receiving proton therapy. This child, the mentor, will show the new child and his or her family the treatment room, demonstrate how to lie still for the treatment, and answer any questions from the child or the parents. The young mentee is then supported through his or her practice session by the mentor, helping the two children develop a special bond. At a later date, the mentee becomes the mentor to another new child. To date, 10 children who were scheduled to receive anesthesia prior to treatment have gone on to successful treatments without anesthesia.

There are a number of advantages to not being anesthetized prior to treatment: Children don’t need to fast, and they don’t need to arrive as early for treatment, thus shortening the length of time in the treatment facility. They also don’t need to wake up from anesthesia, which can be frightening. Receiving anesthesia can extend the child’s time in the facility by an hour and a half to two hours. “The fact that children are able to succeed without anesthesia and go on to mentor other children increases their self-esteem and empowers them”, says Bolton.

Nurses vital to Mass General pediatric proton care team

Cancer diagnosis and treatment is challenging for the most knowledgeable adult patient. For a child, the experience can be even more intimidating and frightening.

Often, it is a pediatric oncology nurse who provides care and comfort, and helps make the experience less scary for children and their families. The Francis H. Burr Proton Therapy Center at Massachusetts General Hospital in Boston, Massachusetts, USA, treats about 175 pediatric patients annually. At Mass General, nurses are trusted members of the integrated cancer care team. The Burr Proton Center treats a number of childhood cancers with protons, including medulloblastoma, ependymoma, astrocytoma, primitive neuroectodermal tumors (PNETs), rhabdomyosarcoma, chordoma and Ewing’s sarcoma.

Rachel Bolton, R.N., is one of four nurses on the proton therapy team, and the only one who works exclusively with pediatric patients. A professional with more than 30 years of pediatric experience, 20 of them in pediatric oncology, Bolton confronts the challenges and embraces the rewards of working with young cancer patients every day.

Prior to treatment, Bolton and the team carefully prepare for the child’s arrival, addressing the particular needs of each family. When family members arrive, Bolton meets with them, either during the initial consult with the child’s physician or on her own. “I want to see how the family is dealing with the diagnosis and talk with the child, if possible, so I can ascertain how well he or she understands what is happening,” says Bolton. She often puts a play mat on the floor and sits with the child so they can interact at eye level. “My goal is to make the children comfortable by letting them get to know me. If the children can feel safe with me, it may help the parents feel comfortable in this very difficult situation.” In addition to a pediatric oncologist, pediatric radiation oncologist and oncology nurse, other care team members include radiation therapists, a physicist, immobilization technician, child life specialist, social worker, psychiatrist, and music and art therapists. To put parents at ease, personal care services such as massage therapy are available.


Getting down to treatment

The first thing children see in the treatment room is a plush turtle that dances to the disco song, “Funky Town.” Placed on the treatment table, the child presses a button on the turtle’s foot to make it dance. “I assure parents that within a week and a half, their child will be asking to ‘go see the dancing turtle,’” says Bolton. “Many parents do not believe me when I say this and are pleasantly surprised when this actually occurs! This shows the child has made that big step toward feeling comfortable in this setting.” Children who need anesthesia for the delivery of their treatment will have their central venous catheter accessed each week. This is often frightening and uncomfortable for the child. However, with the skills of the child life specialist who works with Bolton every Monday, the children can be distracted by her presence and her box of toys. Along with the nurse, the parents accompany the child to the treatment room. The child is held by the parents while the anesthetic is delivered, then they return to the waiting room while the treatment is given and the child recovers. Bolton accompanies those children not receiving anesthesia to the treatment room the first few days to provide support and explain what is happening during treatment delivery. At that time, the children meet the radiation therapist who will treat them with protons and who explains what will happen and what sounds they might hear. “Establishing a routine is important, so the child knows what to expect. Kids are more comfortable when they know what is going to happen.” Bolton says.


Advantages of protons

During her six years at the Burr Center, Bolton has become acutely aware of the benefits of proton therapy, especially for kids with cancer. Cognitive deficits and hormonal changes are only two examples of long-term side effects that could arise for children receiving conventional X-ray  radiotherapy, she says. It is important to remember that the side effects are site-specific. “If you have a child receiving cranio-spinal irradiation, for example, you are radiating the whole spine. With protons, you are protecting the ovaries, the stomach, the lungs,” says Bolton. “There are so many benefits from

protons for these kids later in life.”


Working as a team

The Burr pediatric team meets weekly to discuss each patient — those currently receiving treatment and those awaiting treatment. It is the time to address what other medical, physical and psychological needs the child may have in order to prepare for his or her arrival. This advance preparation is crucial in helping a family feel comfortable and confident with the new care team that will be responsible for their child’s care. “We want to get everyone’s ideas,” says Bolton. “We all come to the table with different strengths and from different backgrounds. And it’s all valuable.” Bolton sees her work not as a job, but as a calling. “I love these kids — they teach me all the time,” says Bolton, the mother of three grown children. “When people say, ‘How are your kids?’ I say, ‘You mean my own or the ones I take  care of?’ For me, they’re one and the same.”


UPenn treating local, recurrent pancreatic cancers with proton beams and chemotherapy

Keen to the targeted cancer-killing power of protons with little radiation exposure to nearby vital organs, radiation oncologists at the Roberts Proton Therapy Center in Philadelphia are the first in the world to use proton beams to treat locally recurrent pancreatic cancer.

As of March 2010, three relapsed pancreatic cancer patients had been treated with a combination of protons and chemotherapy under a protocol devised by James Metz, M.D., and his team at the center, which is part of the Abramson Cancer Center at the University of Pennsylvania Health System (UPenn).

Up until UPenn’s application of protons for localized recurrent pancreatic cancer cases, the therapeutic options and likelihood of success were distressingly limited for patients, says Metz, who is Vice Chair of the Clinical Division and Associate Professor of Radiation Oncology. “Most patients with recurrent tumors go on to hospice and get no treatment at all,” he says.

Newly diagnosed pancreatic cancers are typically treated with a combination of surgery, chemotherapy and conventional radiation therapy when localized. “The challenge is that the pancreas sits amid a number of critical organs, like the spinal cord, both kidneys, the bowel and the liver, which can experience significant damage when you push the limits of photon treatments,” Metz says.  Those limits, he adds, deter the use of conventional radiation on relapsed localized cancers.

“Because of the nature of protons, we can defy the mantra, ‘once you get radiation you can’t get it again,’” Metz says. “With protons, we now have the ability to treat the cancer, minimizing re-exposure of nearby critical organs to radiation.”

Metz and his team first used their protocol to treat a middle-aged woman from a Philadelphia suburb who had experienced her second relapse of an adenocarcinoma of the pancreas.

“She really had no other option,” Metz recalls. “She was first diagnosed four years ago and was treated with surgery, radiation and chemotherapy. She had a local recurrence a year later and received chemotherapy, and responded well. But last summer, the cancer started growing back. She called me and I said, ‘Get in here and let’s look at this.’”

After completing the six-week protocol, the patient has been in remission for more than six months and is doing well clinically, he says.

Metz emphasizes that the three patients treated thus far “have no evidence of disease spread to other parts of the body. These are local recurrences only.” Patients with recurrent pancreatic cancer and evidence of metastatic disease are not appropriate for this treatment, he says.

UPenn’s combination protocol of protons and chemotherapy is also being used for locally recurrent cancers of the esophagus and rectum, Metz adds.

A specialist to care for child’s life?

Cancer diagnosis and treatment is challenging for the most knowledgeable adult patient. For a child, the experience can be even more intimidating and frightening.

Children process information differently than adults, with distinct needs for managing the impact of stress and trauma. A child life specialist understands this unique perspective. Children being treated for cancer at the Burr Proton Therapy Center often interact with child life specialists.

These trained professionals are experts in child development who work in hospitals or other health care settings to help children and families cope with challenging, stressful situations. Easing a child’s fear and anxiety through play, encouraging self-expression, engaging with patients’ siblings, and providing education and resources for parents and other members of the interdisciplinary care team are among the skills child life specialists offer. “Pediatrics is different than treating adults,” says Rachel Bolton, R.N., Francis H. Burr Proton Therapy Center. “Child life specialists are invaluable.”

Siblings not left out

Cancer treatment is a life changing experience for both the patient and its family. For children, the experience can be even more intimidating and frightening. Nurses together with Super Sibs! ensure siblings are not left out.

At the Burr Proton Therapy Center , patients’ siblings are included in playtimes. Rachel Bolton, R.N. is one of four nurses on the proton therapy team. She registers them in Super Sibs!, a nonprofit organization that provides services in the United States and Canada to recognize brothers and sisters of children diagnosed with cancer. They receive support tools, special mailings and items that recognize the unique role siblings have in helping a brother or sister heal. “Parents are grateful for this support, because they realize their other children are hurting, but don’t know what to do,” says Bolton.

IBA, PT world market leader, shares knowledge at conference

Professionals who attended the Planning, Building and Operating Successful Proton Therapy Centers conference, held in Philadelphia, Pennsylvania, USA, in February, received key learning from leaders at the company that has developed and equipped more proton therapy centers than any other.

Yves Jongen, IBA Founder  (Ion Beam Applications) and Chief Research Officer delivered presentations outlining the challenges and rewards inherent in shepherding a proton therapy center project from ground breaking to treating patients. Jongen’s presentation detailed development of proton therapy for clinical use and included snapshots of proton therapy system manufacturers. He provided the following insights:

  • Designing a reliable, user-friendly proton therapy system is a lengthy process, with the typical development cycle spanning seven years.
  • Achieving a viable design, then going from a single prototype to industrial production of proton therapy systems and all they entail is an enormous challenge. Very few companies have demonstrated the ability to install several proton therapy systems simultaneously.
  • The quality of maintenance and operation, as well as a continuous improvement program, are just as important as the initial system design and installation.
  • Finding a knowledgeable, experienced partner to help secure successful financing is crucial.


A number of developers and academic medical centers have spent millions of dollars trying to develop particle therapy projects and have failed. It’s important to have champions on the clinical side and at the executive level who are absolutely committed to achieving success.


Financing proton therapy centers in the United States is more difficult than in other areas of the world, where traditional project finance are more common and easier to navigate. In the United States, teams who want to build proton therapy centers must think creatively.  Many are looking to construction or development division partners for lending, rather than to traditional banks.

Scandinavia’s first dedicated proton therapy center

Skandionkliniken,  the first cancer center in Scandinavia dedicated to proton beam treatments, will be be constructed in Uppsala, Sweden, perpetuating the city’s rich history in the development of proton beam systems for medical use. The center will consist of a proton-generating cyclotron, three beam lines, two patient treatment rooms, a fixed-beam research room and a dedicated pencil beam scanning nozzle.

Adopting an innovative approach to financing the total €100 million project, seven Swedish counties and eight local university hospitals have jointly invested in the new cancer center. Construction of Skandionkliniken on land adjacent to University Hospital is planned to begin later this year. The clinic’s first patients are expected to be treated with protons in 2014. When fully operational, about 1,000 patients a year will be treated at Skandionkliniken, with referrals from clinicians at Sweden’s University Hospitals in Göteborg, Linköping, Lund, Malmö, Örebro, Stockholm, Umeå and Uppsala.

The project’s design can accommodate future expansion. Over the years, research facilities in Uppsala have played critical roles in the advancement of Proton Therapy. In 1957, the Gustaf Werner Institute at the University of Uppsala was the second facility in the world to treat cancer with protons, duplicating a protocol used in 1948 at Lawrence Berkeley Laboratory in Berkeley, California, USA. Patient treatments continued at Gustaf Werner Institute until 1973. Following reconstruction of the research facility and installation of a new cyclotron, the Svedberg Laboratory resumed treating primarily brain and prostate cancer patients in 1989 using a fixed horizontal beam line. “Back in 2003, Swedish health care authorities and clinicians recognized that about 12 percent of cancer patients treated with conventional radiation therapy in Sweden were far more suitable candidates for proton therapy, especially children,” said Leif Lyttkens, Managing Director of Skandionkliniken. “That’s about 2,500 patients a year, far more than the single beam line at Svedberg could ever accommodate. We all agreed it was in the best interests of cancer patients that we pursue development of a national proton therapy center.”

Russia and Belgium invest in nuclear medicine

The Russian Federation and Belgian-based IBA (Ion Beam Applications) will share science, engineering expertise and technology to advance the application of nuclear medicine in Russia and the Kingdom of Belgium and to ensure that the health care of the Russian and Belgian people will benefit from the latest developments in high-tech diagnostic and therapeutic tools.

Those tools include radiopharmaceuticals, proton therapy, brachytherapy, positron emission tomography, radionuclide therapy using monoclonal antibodies, and health information technology.

The trade agreement, signed by executives of IBA and the Federal State Unitary Enterprise (FSUE), Federal Centre of Nuclear Medicine Projects Design and Development of the Federal Medico-Biological Agency, promotes technology sharing of numerous medical innovations relied upon particularly in the diagnosis and treatment of cancer. “Today, scientists in Russia and Belgium are agreeing to work together to win the biggest fight we have ever faced, the fight against cancer,” says Yuri Khalitov, Director of FSUE. “By sharing scientific discoveries, design and engineering expertise, and innovative production practices, our nations can equip our doctors and nurses with the latest advancements to diagnose and treat cancer, and improve the quality of life of cancer patients.” “When a friend or family member is touched by cancer, we want the best for them,” says Serge Lamisse, President/Sales and Marketing of IBA. “This agreement commits that we work together to develop and provide the best cancer-fighting tools for the people of our two countries.”

Under the pact, FSUE and IBA scientists and engineers will develop joint research ventures involving nuclear medicine in cancer diagnosis and treatment. They will share their expertise at scientific seminars and conferences and advise one another on innovative approaches to nuclear medicine-related practices. This joint Institute of Nuclear Research pact also aims at developing accelerator technology in terms of design and engineering.

New PT center In Knoxville, Tennessee

ProVision Trust and The Proton Therapy Center, LLC (TPTC) are installing a proton therapy facility in Knoxville, Tennessee, USA.

The Proton Therapy Center at the East Tennessee Healthcare Center will be a two-story facility with three treatment rooms and the capacity to serve about 700 patients a year. The project is expected to draw about half of its patients from neighboring states such as Kentucky, North Carolina, Virginia and Georgia.