For all its cancer treatment advantages, the business end of proton therapy is synonymous with massive gantries and investment costs in the hundreds of millions. However, new developments from manufacturers are changing the calculus around protons, and ushering in a future where systems may require no gantry at all, and significantly lower upfront costs to providers.

P-Cure and Mevion are among the companies working to reimagine the way protons are delivered. The MEVION S250-FIT cyclotron, developed in partnership with Leo Cancer Care, is self-shielded, and the P-Cure system requires 50% less shielding than a traditional gantry room. B dot Medical in Japan also has a smaller-footprint proton therapy system called the Phemto that utilizes a much smaller gantry than traditional proton therapy. Of these systems, only P-Cure is FDA cleared and clinically available in the U.S.

As opposed to traditional proton therapy systems that treat patients in a supine position, the MEVION and P-Cure systems can treat patients upright in a chair. Rather than utilizing a gantry to rotate the beam around the patient, the beam comes from one direction and the chair rotates the patient.

"You either have the possibility to rotate the beam around the patient and keep the patient steady or to keep the beam steady and rotate the patient as you need,” explained Joern Meissner, CEO of Meissner Consulting and an expert on the subject of proton therapy installations. “The latter one does not require large magnets or large equipment and allows for smaller installations."

These upright systems have customized the robotic positioner so that the chair has six degrees of freedom, according to Meissner. Patient setup is relatively simple and imaging is integrated into the system. Administering treatment in an upright position also means there is no gravity-based organ movement, as the imaging and treatment are done in the same position, which may also offer clinical advantages.

An upright system can often fit into an existing linear accelerator (linac) vault, but Meissner explained that more often than not, the concrete contours inside the linac vault have to be modified and additional shielding may also be needed.

"For me, the upright treatment cost reduction is not so much in retrofitting an existing linac vault,” he added. “If you have an existing cancer center with a small parking lot next door, you can add proton therapy by building a quasi-linac-sized bunker for much less money than if you added even the smallest commercially-available proton bunker with a gantry.”

An existing center already comes with diagnostics, nurse stations, and all the other clinical support areas and all you have to add is a proton vault with space for the necessary auxiliary systems. In addition to reducing costs associated with the bunker size, you also reduce your operating costs, since less electricity is needed.

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