Talk:Proton therapy/Archive 1

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Unclear paragraph

I think that the following paragraph is poor:

"The logic for treating common cancers (for example lung, head/neck, etc) with proton therapy is the same as saying that surgery alone should cure most cancers, as surgery is the Definitive Local Treatment. Of course, surgery does not - because most cancers spread microscopically very early beyond the tumor ('local') site."

My criticisms are;

(1) Proton therapy NEVER claims/claimed to cure most cancers, it is simply an improvement on localised X-ray therapy. This rules this para out of the Pros/Cons section. I will either rewrite much of this or delete within 2 days. Jefferson61345 (talk) 11:38, 14 September 2008 (UTC)

I restored this text because there was no edit summary attached to the deletion, making it look like random vandalism. Sorry. Next time I'll remember to check the talk page first. Let me slap the {{fact}} template on that text, and if no one supports it with a reference, I'll delete it later (unless someone else deletes it before I do). --68.0.124.33 (talk) 22:44, 22 February 2009 (UTC)

The Promises and Perils of Proton Radiotherapy - Using Children to Justify New Technology

This section has already been flagged due to its tone or style. Further, not a single word has any bearing on the "The Promises and Perils of Proton Radiotherapy". One could delete this entire section and not lose a moment's sleep over it - in fact the article would be improved in my view. Rather than just abruptly nuke it, I wanted to mention it here to see if there were other opinions? Sdenny123 (talk) 03:20, 21 June 2009 (UTC)

I would favor deleting in, or at least significantly rewriting it and moving it further down. The issues about treating pediatric patients are clearly complicated. Not every pedi patient need protons, not every pedi patient can afford to travel/stay at one of the few centers. Reimbursement is biased toward treatments that take many fractions (which is prostate), so that in order for a facility to be built privately (and repaid, and cover operating costs), it is necessary to treat some adult patients. If adults were to be disallowed, it would be highly unlikely to be financially viable to build a proton facility. The alternative is for the government to just built the facility itself (the European/Japanese model), and then it can treat whoever benefits "most". The LLUMC data table is clearly biased; if anything, it should be a recent data table summarizing *all* proton patients treated worldwide. At any rate, I think the tone of the passage is very biased.Tdvorak (talk) 02:53, 26 June 2009 (UTC)
The content should remain as it is factual, logical and has citations from legitimate sources. Also, the content is on target with respect to the opinions and practices of the decision makers in the field. By all means get busy and do the research, cite your source and add it to the article. Also note that there was a symposium on "The Promises and Perils of Proton Radiotherapy" in Baltimore, MD, USA and many of these issues were discussed by the attendees. One could learn a lot if the video content from the two day conference is ever made publicly available. mdphd2012 (talk) 21:48, 26 June 2009 (UTC)
The article entitled "The Promise of Proton-Beam Therapy" by Adam Voiland published by US News and World Report on April 16, 2008 touches on the topics of: a.) prostate being a sizeable percentage of the patient treatment population, without sufficient "unbiased" evidence supporting its efficacy. b.) financial motivation being a push for the prostate patient to be a sizable quantity 30-50% of patient's treated by proton therapy. c.) Cites that children are the ones to benefit the most, but treating kids does not "pay the bills". Therefore arguing that one needs more proton centers to support the treatment of children. [1] mdphd2012 (talk) 07:18, 7 July 2009 (UTC)
I don't disagree with the overall content of the post. However, I am bothered by the tone. Briefly perusing it, the content uses citations selectively. For example, a sentence states that For example radiotherapy advertisements often use children to sway public opinion in the development and adoption of a costly technology. There are 2 references. Both are newspaper articles, and neither of them says anything about radiotherapy advertisements or how they sway public opinion. They report on the difficult choices proton facilities have to make. I have briefly looked around and haven't seen any advertisements that would use children to sway public opinion, and would be interested in seeing one. Browsing MD Anderson's website, their top patient education resource is mostly about prostate and lung, with a small mention of pediatrics. Similarly, I haven't seen any obvious such ads at MGH website. The ads I do recall seeing were mostly about prostate, or disease-agnostic.
Entering "proton therapy children" as criteria for a popular web based search engine yields quite a number of search engine hits. Please try that search combination. (Sorry user Tdvorak, I would like to avoid writing your wiki textbook for you.) mdphd2012 (talk) 22:41, 5 July 2009 (UTC)
Another sentence states Of the 1,437,180 new cancer cases diagnosed in the United States for one year: 15% of these are prostate cancer diagnosis, 0.05% (11,000) of these cancer cases are children. Critically thinking with these statistical values assumes that a well informed pediatrician allows every child diagnosed with cancer to be treated with radiotherapy. Unfortunately, the article doesn't go on to critically think with these numbers. What's the point of this information with respect to the article? That there are lot more adult cancers? Many cancers/cancer patients are not treated with radiation, at least not until they become locally advanced or metastatic. This is even more so true for pediatric patients. While true, it has no bearing on perils and promise of proton therapy. Similarly, citing just old Loma Linda numbers is biased. I tried to briefly look around and didn't see any good breakdowns on actual number of patients treated by disease. Lodge (PMID 17502116) performed a systematic literature review of published literature, and vast majority of those were ocular tumors. I suspect that excluding Loma Linda, majority of patients treated with protons in all the other centers worldwide would in fact not be prostate. Using the one center that is explicitly treating prostates, while ignoring the other >25 centers is biased. I would love to see recent overall data, if available.
How many children need to be treated with proton therapy? In the US it can not be more than around 11,000. One center turned away ~45 children. That means child number 46 never showed up asking for treatment. So which number is correct? 11,000 or 45. It is probably more like 200 but wiki policy requests that the facts should be published. The >25 centers should be honest with the community and publish a breakdown of their treatment load and the wiki article provides one transparent template for reporting this information. (The original article that I cite does an even better job reporting the treatment load by disease site and year!)
A "bias" does occurs if a treatment center elects not to publish their overall data. I see that you are a physician at Brown, so perhaps you would be willing to share the breakdown of patients that your center treated? Other than the general breakdown, how many are pediatric patients? More specifically how many children treated at your center would benefit from proton therapy? How many children treated at your center would benefit from x-ray therapy? Keep in mind if your results have not been published then you can not cite them in wiki!
Note that ocular tumors can be treated by other therapies. mdphd2012 (talk) 22:41, 5 July 2009 (UTC)
While I agree that the content of the section is important, and that it is an issue with which radiation oncology as a specialty is grappling with, I think this passage is written in a sensationalistic style more suitable to a newspaper than wiki (especially the first paragraph, which does not back up its assertion with any reliable sources, and is guilty of the same appeal to readers of which it accuses proton therapy centers).Tdvorak (talk) 02:36, 30 June 2009 (UTC)
Thank you for agreeing that the content of the section is important. Therefore since the content is factual, has legitimate citations, and even you agree that it is important, we now conclude that it should remain. mdphd2012 (talk) 22:41, 5 July 2009 (UTC)

I reinstated the inappropriate tone banner that mdphd2012 removed. The tone of this section is still more like a magazine article and not in line with Wikipedia's style. I think this section should be moved toward the end of the article, where "Criticism" sections are conventionally placed in WP articles, or preferably deleted entirely. 75.161.78.202 (talk) 08:09, 21 July 2009 (UTC)

The section really ought to be deleted. It might have some place elsewhere in the Wikipedia, but it doesn't make any sense to have it here. The title is bizarre, the tone is biased, its argument consists of original research ("Critically thinking with these statistical values"), it seems to be supported only by one person (who seems to have an axe to grind), and it was inserted at a preposterous position in the article, nearly at the top. There certainly isn't any "conclusion" that it should remain. 91.37.224.183 (talk) 20:10, 21 July 2009 (UTC) —Preceding unsigned comment added by Sdenny123 (talk • contribs)
Re-reinstated tone banner. Please don't start an edit war. Address the underlying issues (i.e. tone and appropriate placement in article) or remove the section. 75.161.78.202 (talk) 02:02, 25 July 2009 (UTC)
I really think this section should simply be deleted. The tone and content are more appropriate for a magazine article about the issues of access to proton therapy, rather than an encyclopedia article about the treatment modality. There is also out of date information, factual errors, and inappropriate comment. While there is controversy within the proton therapy community about the tendency of some (but not all) facilities to fill their slots with prostate treatment due to the lucrative potential, this does not apply to the treatment modality in general (for instance Mass General Hospital devotes only 10% of proton treatment slots to prostates). I considered re-writing it in a more accurate and balanced manner, but realized even that would read more like a newspaper or magazine article than an entry. All this being said, I feel strongly that it should just be deleted. AE1978 (talk) 13:37, 25 August 2009 (UTC)
User AE1978 should note that "photon" is a descriptor often used in describing then entire spectrum of electromagnetic radiation. Using the phrase "photon therapy" is misleading. For example the scientific word "photon" can include portions of the electromagnetic spectrum such as the optical, infrared and radiowave spectrum. I changed your phrasing from "photon therapy" to x-ray therapy and included a reference to brachytherapy. X-ray radiotherapy (more precisely external beam x-ray radiotherapy) and brachytherapy are more germane to the topic of this article. Keep up the your physics studies so that one day you too can make a meaningful scientific contribution! Mdphd2012 (talk) 21:45, 26 August 2009 (UTC)
I think you have me confused with someone else, I am not responsible for the use of the term Photon Therapy in this article. Nonetheless I feel compelled to make the following comments; 1. While mdphd2012 is technically correct that the the term "photon" refers to the entire electromagnetic spectrum (as those of us with a nuclear physics background are well aware of), within the clinical physics community "Photon Therapy" is the most commonly used terminology for conventional X-ray radiotherapy. As this article is about a clinical application, it is a perfectly acceptable terminology (and I've been involved in this field for too many years to get worked up about the often inconsistent and vague terminologies common in clinical physics). 2. In response to your comment about my "physics studies" I would say; perhaps when you have been involved in proton therapy for more than two decades as I have, you too can make a significant contribution to the field. AE1978 (talk) 18:38, 27 August 2009 (UTC)
AE1978 I just read an article in the October 2009 issue of the American Association of Retired People on prostate cancer treatment. What is my point? You are using imprecise language and you are writing solely to people within your field when using "Photon Therapy". i.e., You are not writing to the readership of Wikipedia. On occasion we all make that mistake and should take responsibility for it.
Use your experience to contribute to the article as per Wikipedia guidelines as I do. Maybe you can add something on brachytherapy and how it compares to proton therapy? After all brachytherapy has a higher skin sparing effect than protons for prostate cancer. Since you have been in this field for so long, perhaps you know where the previous centers have published a breakdown of the patients that they treated with proton therapy? Take the time to cite published articles. Mdphd2012 (talk) 20:02, 27 August 2009 (UTC)
mdphd2012, I really think that the section you wrote on the issues involving access to and appropriate use of proton therapy has a very inappropriate tone for an encyclopedia. As you seem to be reactive to discussion, let me propose the following. Remove the section as it is presently written and I will ad a section (placed towards the end of the article) titled something like "Controversies surrounding the cost and proper use of proton therapy". You see, I agree with you that prostate treatment is a problematic application of proton therapy, and share your concern with the tendency of some centers to push (market) that use. I just think a more reasoned and less sensationalist treatment is called for in this context. As to the Photon Therapy vs X-ray Therapy issue, I am fine with the use of the term X-ray therapy (in fact I prefer it), I just felt that you were being unnecessarily harsh in your criticism of whomever it was that did choose to use that term. As to the issue of published data, unfortunately there is not a lot out there that gives good breakdowns of patient statistics. I will speak to some of the more clinical people here (I'm more physics than clinical) and see if there is something I'm not aware of.AE1978 (talk) 22:27, 27 August 2009 (UTC)
AE1978 I choose to avoid publicly identifying myself and rely on published articles for the facts. At least the authors of these articles are in some small portion accountable for their statements. Whatever experience I can offer, simply guides me in asking questions. I then use this experience to find articles that contain a potentially accurate answer. The key is asking the right questions. For example note that asking, "Should proton therapy undergo clinical trials to determine the efficacy of its application to a particular disease site?" presupposes that one will apply proton therapy. It bypasses the question "Should one even use proton therapy?" Note that asking the question, "Is proton therapy worth the costs?" also bypasses the question, "Should one even use proton therapy?" If the answer is always "yes" or "no", then you should take a close look at your experience with this radiation oncology application. Mdphd2012 (talk) 17:40, 28 August 2009 (UTC)
mdphd2012 I'm somewhat confused by your reply. First of all I never asked for you to identify yourself. Second of all, you did not respond to my attempt to find a reasonable solution to this impasse. I'm tying to be fair to you as you clearly have knowledge about, and care about, the subject. However, the fact remains that the section "Promises and Perils...." is inappropriate in tone (and inaccurate in content). There is a unanimous consensus among all of the users other than yourself that this section needs to be deleted or radically re-written. I am trying to avoid simply deleting it again without giving you the chance to help produce a version that can stay.AE1978 (talk) 13:58, 30 August 2009 (UTC)

Take the time to learn your field and cite published articles. Mdphd2012 (talk) 21:46, 26 August 2009 (UTC)

ModernMedicine from Nation Public Radio put out an article "When Is Proton Beam Therapy Worthwhile?‎" This article points out that proton beam therapy was not curative for Senator Edward M. Kennedy of the USA who passed away yesterday. Senator Kennedy's proton treatment was supported by US Medicare. This puts a spotlight on proton therapy so I expect that the number of edits are going to rise. —Preceding unsigned comment added by Mdphd2012 (talk • contribs) 20:19, 27 August 2009 (UTC)

Call to all interested users. What do you all think about the issue of should "The Promises and Perils of Proton Therapy....." be deleted (again, I believe that it has already been deleted 3 times by 3 users) unless it is radically revised??? I strongly think it should be.AE1978 (talk) 16:17, 30 August 2009 (UTC)

It appears that vandals are trying to take charge of the proton therapy page. For the most part they seem to be deleting content sometimes as a registered user. —Preceding unsigned comment added by Mdphd2012 (talk • contribs) 19:40, 31 August 2009 (UTC)
I would say that the only vandalism I've seen on the page has been by you, mdphd2012. You have consistently undone any edits by any users of your contributions. I attempted to engage you in a reasonable discussion through which we could achieve consensus, and you have been completely unreasonable. I am going to restore the last edits that I made (and that you undid). I will also delete the section "The promises and Pitfalls of Proton Therapy..." as the consensus of the discussion page indicates. If you revert these edits I will report you to the Wiki Eds and engage the official conflict resolution process.AE1978 (talk) 18:23, 1 September 2009 (UTC)
I've already stated my opinion that this section does not belong here. I was reading along and suddenly fell into bizarro world. Perhaps it deserves its own article where it can be properly expanded into a legitimate op ed piece and then speedily deleted? Sdenny123 (talk) 23:32, 31 August 2009 (UTC)
I liked your material on Cambridge and ocular treatments. It sits well with the fact that most new proton centers are aggressively pursing prostate treatment by building higher energy machines. It also points out that most of the previous facilities were built and operated by staff who had extensive experience in particle physics and medicine. Now in a hospital setting, as opposed to a national lab, those people are replaced by the average Joe down the street who works for a minimum wage. In general these people do not know the difference between a proton, photon, gamma ray and x-ray.Mdphd2012 (talk) 03:55, 3 September 2009 (UTC)
mdphd2012, while I agree with many of the issues you raise, and I am (like you) concerned with the lack of specific proton knowledge within the larger hospital based treatment system, you are overstating the case (I've never seen a radiation treatment facility, conventional or proton, where treatments are planned or delivered by "Joe down the street who works for a minimum wage"). Nonetheless, the larger issue that we need to deal with is the fact that you keep overriding all other editors decisions. The consensus on this discussion page is that "The Promises and Perils....." section DOES NOT BELONG ON THIS PAGE. The tone is inappropriate, the content is inaccurate and outdated. It does not help you get your point across to keep restoring an entry that strikes the reader as "bizarro world" or "like a magazine article" or "stands out like a sore thumb" (to quote a few of the other editors), yet you insist restoring it over and over. You also removed other editors inappropriate tone banners etc, as well as reverting more minor edits without reason. If this is not vandalism I don't know what is. I have attempted to engage you in a dialog so that we might achieve a consensus, but you don't seem to be interested in that. For all these reasons I have opened a Wikiquette alert on your behavior, mdphd2012. This does not mean that I'm giving up on finding some consensus solution, and I am working on an entry (complete with recent patient stats & references) that addresses some of the issues you have raised in a more reasonable and accurate manner. AE1978 (talk) 13:14, 3 September 2009 (UTC)

Note to all editors: I added a new section "Controversies concerning the appropriate application of proton therapy". I believe that the contetnt of this section incorporates some of the issues of concern to mdphd2012. Let me know what you think.AE1978 (talk) 16:49, 3 September 2009 (UTC)

"Controversies" section head is good to avoid. If there are controversies, they need to be sourced... that is, some wp:RS needs to say something like "...there is controversy over whether blah blah blah...". If there is simply disagreement... I must ask whether there is ever NOT disagreement... the differing views need to be presented neutrally. The reader can decide if that is controversy, or just differing opinions. Give my reorganization a look? Easily done differently, it is just an idea.- sinneed (talk) 18:28, 3 September 2009 (UTC)
Thanks Sinneed, I think that that works very well. I also approve of gathering these sections all under the "comparisons.." banner.AE1978 (talk) 16:58, 6 September 2009 (UTC)
Added 2 sources for the controversy, also a source for the $150M cost (yikes).- sinneed (talk) 21:42, 3 September 2009 (UTC)

Personal Communication

" Dr. H. M. Lu, personal pommunication, Mass General Hospital (2009)" - this would fail wp:V, at the least. Even if somehow it did not, it would be self-published.- sinneed (talk) 04:14, 8 September 2009 (UTC)

Hi Sinneed, I'm trying to scare up a published source for this infoAE1978 (talk) 23:47, 8 September 2009 (UTC)

Table of Loma Linda UMC treatment stats is somewhat interesting, but seems widely off-topic

What does this tell us about Proton therapy? It tells us about LLUMC... which can have its own article if it needs one.- sinneed (talk) 03:25, 13 September 2009 (UTC)

Expanding - Do we have a wp:RS that says the LLUMC's usage is typical? Or different? It is a single data point.- sinneed (talk) 03:27, 13 September 2009 (UTC)
I think that the LLUMC % of TX slots is reasonable to include, but the entire table is too much and doesn't add anything to the section.AE1978 (talk) 17:13, 16 September 2009 (UTC)

The LLUMC data is typical of the application of proton therapy in a "hospital" setting. Note that it is very important to differentiate between a "hospital" facility and a "research" lab. To clarify the point note that any new "hospital" facility, i.e. not a refurbished research lab, will include higher energies. The higher energies are used for treating more deeply seated tumors. The "test" application of proton therapy to, say, ocular tumors is motivated by the fact that the tumor is near the skin surface, had little geometric mobility, requires a low energy, could be visualized very easily and is correctable by resection. (Other techniques have since occluded proton therapy as the treatment of choice in ocular tumors.) Hence the referenced table numbers in the Van Dyk book have a more deeply seated interpretation. The complete table from the reference shows that LLUMC started with simple shallow diseases. LLUMC then evolved to spending the majority of its treatment capacity treating the prostate. Mdphd2012 (talk) 04:23, 13 September 2009 (UTC)

The LLUMC data is typical of some (I might even say too many) hospital based facilities, but not all. I would also take exception with md2012's statement above that ocular tumors are the "test" application of proton therapy. Historically the earliest application was in stereotactic radiosurgery, and then base of brain and spinal tumors, then ocular tumors. While the ocular treatments are very effective, so are the treatments of chordomas, chondrosarcomas, paranasel sinus tumors etc, all of which can require high energy. I also do not think that the statement "Other techniques have since occluded proton therapy as the treatment of choice in ocular tumors" is supportable. AE1978 (talk) 17:13, 16 September 2009 (UTC)
  • "Do we have a wp:RS that says the LLUMC's usage is typical?" - Guessing "no", but it certainly isn't in the article at the moment.
  • "LLUMC then evolved to spending the majority of its treatment capacity treating the prostate." - Not really, no. It looks like it always treated a lot of prostates. The ratio against "Head and Neck" is a bit higher... but not a great deal.- sinneed (talk) 04:37, 13 September 2009 (UTC)
"it is factual and cited"
  • I could add the lyrics to "I'd Rather Be A Hammer Than A Nail", in French, and that would be factual and cited.
  • Does ANYONE working on this article other than the adding editor support the addition of the LLUMC table to the article? - Sinneed (talk) 03:08, 17 September 2009 (UTC)
  • I oppose. Just one hospital, just a table of information useful only to a very few, and readily available at the source, which is listed, if needed. Not encyclopedit, too undue weight to LLUMC, breaks up the article. Adds nothing, and detracts. - Sinneed (talk) 04:53, 17 September 2009 (UTC)
I also oppose, same reasons as Sinneed sited above. Please remove.AE1978 (talk) 16:33, 17 September 2009 (UTC)
The LLUMC table should remain. It provokes the correct analysis. Find data fro other centers to indclude in the table and you will have something truly informative.Mdphd2012 (talk) 05:39, 17 September 2009 (UTC)
  • You will need to be more convincing to have this addition in the article. wp:consensus is against you. I see no reason not to leave this in a day or 2 more in case others decide to comment. Any objection to leaving this up briefly for that reason? - Sinneed (talk) 18:42, 17 September 2009 (UTC)
I agree, give it a couple of days and then cut if if there are no objections.AE1978 (talk) 23:16, 17 September 2009 (UTC)
  • Well the adding editor was in a great hurry to delete content instead of reworking, and I moved ahead. The content is there in the history should either other interested editors join the discussion or the adding editor pursue new arguments for inclusion. I have wp:COPYVIO concerns and felt bad about leaving it up as-is anyway, even with my wp:QUOTE on the COPYVIO header... how do I quote a table? Cut. - Sinneed (talk) 05:38, 18 September 2009 (UTC)
  • Nothing new has been added in some time, and this is being re-added again.- Sinneed 03:47, 18 October 2009 (UTC)

Part Deux: Table of Loma Linda UMC treatment stats is somewhat interesting, but seems widely off-topic

Found some treatment stats for Fracis H. Burr Proton Therapy Center for a talk by Thomas F. Delaney, M.D. given at PTCOG 47.

http://ptcog.web.psi.ch/PTCOG47/presentations/4_Meeting_Thursday/TDelaneyupdate.pdf

It gives a great breakdown of the patients treated between 11/2001 and 9/2006. It starts by saying that the center treated about 2003 patients. Then shows that the breakdown was

  • Adults 1478 (74%)
  • Pediatric 257 (13%)
  • Stereotatic 268 (13%)

The talk goes on to parallel the stats that I originally put in a table from another hospital center.

Harvard thinks these type of stats are important and another proton therapy thought the stats were important. The article should have the a new table inserted with stats from both proton centers.

It also supports the original question asking:

"What capacity does the US need to treat the population of children with cancer? One article suggests that a possible estimate of 45 children, i.e. one third, were denied treatment due to limited resources at a proton center.[3]

Noting that child number 46 never showed up asking for treatment, one can approximate that this center needed to handle a capacity of 180 children per year. It is worth noting that the care put into treating children involves 2-4 times the resources than more conventional cancer treatments. Therefore approximately 200 adults would have benefited over the 45 children. One proton therapy center has a capacity to treat 140-150 (adult) patients per day. This capacity averages out to a mixture of 1,000 patients in one year [2]."

I estimated a need for a treatment capacity of 200 hundred children per year and yet Harvard only treated 257 over a five year period. It certainly begs the question "Why are all those other proton centers being built?" Mdphd2012 (talk) 01:13, 21 September 2009 (UTC)

  • Having nothing to do with proton therapy.
  • Maybe a new article, if you can find enough notability for it called something like "No need for more proton therapy centers globally" or whatever. What is all this going to tell an encyclopedia reader about proton therapy? I don't see anything useful on the subject of "proton therapy".
  • I struggle to wp:AGF in this, it all seems to be to hammer home your wp:POINT...proton therapy is expensive, there are too many centers, people are profiteering, people are using child illness as an excuse to develop and pay for staggeringly expensive gear, etc. Maybe it would fit in some of the health care reform bits, or a new article or new articles... but I don't see it here, and I continue to oppose. I am listening, but I am not hearing anything convincing. Does any other interested editor support the inclusion?- Sinneed 01:49, 21 September 2009 (UTC)
  • Do you have an alternate proposal that does not involve having these huge tables in this small article? I have not been able to come up with one, at the moment and would love to hear ideas.- Sinneed 01:49, 21 September 2009 (UTC)
  • Also, please remember wp:QUOTE. You have been warned about this before. Yes, short quotes are allowed... but you must quote. How do you plan to address the larger issue of quoting their entire tables? The heading can (and must if they are being quoted) be... quoted. These issues apply here on the talk page, and everywhere in WP, these must be corrected.- Sinneed 02:11, 21 September 2009 (UTC)
  • Please again consider including the key points that will provide useful information about proton therapy to encyclopedia readers. The value of these tables to people trying to decide whether to build a proton therapy machine is quite clear. But if someone is using to an encyclopedia article to make a quarter billion-dollar decision something is very wrong.- Sinneed 02:11, 21 September 2009 (UTC)
  • OK, if we reach consensus to have these, please consider collapsed tables so they are not So Huge.- Sinneed 02:17, 21 September 2009 (UTC)
Within the context of including the tables:
* I think the collapsing table is neat. It might be the best suggestion for the content until something more creative comes to mind. Mdphd2012 (talk) 04:03, 21 September 2009 (UTC)
No, the best suggestion for the content until someone shows that it belongs in the article is to leave it out. Also, wp:copyright - address.
* wp:verifiablity is met. Concerns for wp:quote are misplaced as the data in the table format were not used in the original presentation. Some manual of style would allow one to provide a reference to cover the table values. Otherwise applying this policy to everything would require all content in wiki to be in quotes. Mdphd2012 (talk) 04:03, 21 September 2009 (UTC)
* So much is so wrong I can't even imagine how to begin. Just no.- Sinneed 04:22, 21 September 2009 (UTC)
* wp:point is of concern to me. Specifically: If somebody suggests that Wikipedia should become a majority-rule democratic community (e.g. consensus) do point out that it is entirely possible for Wikipedians to create sock puppets and vote more than once. Along that line I would point out that the world was believed to be flat until enough people could be convinced that it was round. A good table or graphic is not only needed, it will provide data to identify trends. The Harvard table shows less then 10% of patients are prostate cancer patients. So what does this mean? Is it because the center needs more upgrades? Do they think that prostate is not the ideal application? I do not yet know. Mdphd2012 (talk) 04:03, 21 September 2009 (UTC)
Just a pointof information. TheHCL/MGH collaboration studied the use of protons vs photons (X-rays) for prostate (see Zeitmen's paper) and determained that is only worth using protons in a very small percentage of cases. Thus the MGH treatment program (now at The Burr Proton Tehrapy Center) only deotes ~ 10% of it's cpapcity to prostate. So, yes it is because (in mostr cases) prostate is not the ideal application. Unfortunately we (and most other centers) do not typically publish our patient breakdown stats (back at HCL we used to keep close tabs on the treatment breakdowns for us an oethr facilities, but in the transfer of technology to the hospital setting that tradition seems to have been lost).AE1978 (talk) 15:46, 24 September 2009 (UTC)
  • Please read wp:consensus. Again and again you make statements that show you do not understand. wp:NOTa democracy - Please read wp:consensus. This article is not about trends in constructing treatment centers. It isn't about treatment centers at all. It is about proton therapy. Perhaps WP needs a Proton therapy treatment centers article. But this is not it.- Sinneed 04:19, 21 September 2009 (UTC)
* The best I can do is get the facts on the table (all puns intended) and see who follows them. If my logic is faulty some creative editor will find the hole in my thinking and add appropriate content to clarify the issue. The problem is that deletion has been the method of debate instead of adding intelligent discourse. Along this line, another editor claimed I should allow another section to be deleted and then the editor would step in and make it right. While I am waiting for this I keep adding appropriate material. Mdphd2012 (talk) 04:03, 21 September 2009 (UTC)
* No, the best you can do is to provide neatly summarized, wp:NPOV content, based on wp:Reliable sources, and write an encylopedia. Focus on the content. ANd here, that is about proton therapy.- Sinneed 04:19, 21 September 2009 (UTC)
* With regard to thinking globally, perhaps you should consider that we might need two sections - proton therapy globally and locally (US). The question is which world arena influences the other, right? Mdphd2012 (talk) 04:03, 21 September 2009 (UTC)
* Nope. This is an article about proton therapy, not about some nebulous social/economic/political chat. This is an encyclopedia. Focus on the content.- Sinneed 04:19, 21 September 2009 (UTC)
* Ultimately treatment capacity is the question. How much do we need? What do we need it for? Who is funding it? Are they qualified? Do they know what they need? Will they ask for too much and then have to find a way to fill their capacity? Mdphd2012 (talk) 04:03, 21 September 2009 (UTC)
* No, it isn't. NONE of those questions belong here. This is an encyclopedia. It is not a discussion board for the future of proton therapy center capacity. Possibly there is a need for an article called proton therapy capacity in the US or proton therapy capacity globally but this is not it.- Sinneed 04:19, 21 September 2009 (UTC)

Please focus on the content of an encyclopedia article on proton therapy. Everything here, every conclusion, every point, should already have been made in the literature.- Sinneed 04:19, 21 September 2009 (UTC)

I thought the table was very useful. I am a student in this field trying to figure out where I can work and still have a job in 10 years. It looks like prostate cancer is the future of proton therapy, even if it is a poorer choice for patient outcomes. A person has to eat you know! —Preceding unsigned comment added by 66.134.115.34 (talk) 18:31, 19 October 2009 (UTC)

And you still have a wp:COI, and you still are not following wp:talk page guidelines and you still have not shown any reason to include these tables in the article about proton therapy. If you want to start an article about careers in proton prostate cancer, I am dubious about your finding enough information to create an article, and this is not it. This is an encyclopedia article about proton therapy.- Sinneed 18:39, 19 October 2009 (UTC)

Wow, my professor was right. Wikipedia does not publish the facts. 66.134.115.34 (talk) 18:43, 19 October 2009 (UTC)

wp:talk page guidelines - this is not a forum for discussion of WP nor a place for wp:personal attacks. Focus entirely on the content of the article.- Sinneed 19:09, 19 October 2009 (UTC)

Application of proton therapy

I am trying to improve this edit. The broad categories should be based on targets that have a high degree of mobility, i.e. have tumor motion, and the targets that have little or no mobility. This is because the advertised precision due to protons, i.e. the experimental error bars of proton therapy, loses meaning when you consider that many conventional radiotherapy disease sites and patients have mobility. Mdphd2012 (talk) 04:23, 13 September 2009 (UTC)

I strongly disagree with this point. The two broad classes listed are the classes of typical proton therapy application, not tumor sites. Protons are not typically used to treat highly mobile tumors (if you want to add a sentence that states that fact, with reference, I would have no objection). I would also point out that reference 10 (R. P. Levy et al,"The current status and future directions of heavy charged particle therapy in medicine", AIP Journal, March 2009) separates proton therapy applications in exactly this way when talking about the historical development of proton therapy applications.AE1978 (talk) 17:13, 16 September 2009 (UTC)
Then it sounds like you are trying to edit to prove a point, rather than to provide information about proton therapy (edit to add) that appears in published, reliable sources. Just find a wp:RS that says "The advertised precision due to protons loses meaning when you consider that many conventional radiotherapy disease sites and patients have mobility." or some such, put it in the article and be done. If there is no such wp:RS, then you are running into wp:SYNTH.- sinneed (talk) 04:37, 13 September 2009 (UTC)
Cited a stat on a form of ocular melanoma, e.g. uveal melanoma. Mdphd2012 (talk) 04:38, 24 September 2009 (UTC)
Do not have access to the article which goes along with the other prose "For another ocular tumor a study claims a 5-year-survival{{CN|date=September 2009|I can't see and don't have the source, is this correct or is this a "local control" reference) rates approaching 95%.[24]" one can find the abstract here [3]. An excerpt from the abstract states that for 2069 patients studied
"Results: Tumor regrowth occurred in 60 patients, and 95% of tumors (95% confidence interval, 93%-96%) were controlled locally at 15 years. Risk scores were developed for the other 3 outcomes studied. Overall, the treated eye was retained by 84% of patients (95% confidence interval, 80%-87%) at 15 years. The probabilities for vision loss (visual acuity worse than 20/200) ranged from 100% to 20% at 10 years and for death from tumor metastases from 95% to 35% at 15 years, depending on the risk group."
The two articles share a few authors. It is quite possible that 'local control' is maintained with retreatment. Re-treatment might involve enucleaction which is not proton therapy so this should be weighed carefully. Mdphd2012 (talk) 04:38, 24 September 2009 (UTC)
I can assure you that the numbers in the Gragoudas paper did not include re-treatment or enucleation. As to the discrepancy between the two, I would tend to trust Graggoudas' numbers (as he was the referring physician). Why don't we say "cure rates on the order of 90%." and reference both papers?AE1978 (talk) 13:12, 24 September 2009 (UTC)
Local control here misses the point that 20% of the patients died due to metastatic disease from the primary ocular tumor. Therefore the statistic of 90%, or 95%, is misleading. See death from tumor-related causes in the paper [4]. —Preceding unsigned comment added by Mdphd2012 (talk • contribs) 20:46, 29 September 2009 (UTC)

I propose that we remove the paragraph giving specific detailed results for the ocular tumors. We don't go into such detail about any other specific treatment, so why this?AE1978 (talk) 19:18, 24 October 2009 (UTC)


Pasting from sources?

I had thought it appeared that much of this was pasted from an essay. Is this being copied from other sources? If so, it MUST be quoted, and the source being quoted from identified, even if public domain. See wp:quote. Yes, journals can indeed essay. They contain a great deal of opinion, question-and-answer-to-lead-the-reader. That is not done in an encyclopedia. This is not a blog, not an editorial, it is an encyclopedia. Just summarize and let the reader go see the source if interested. - Sinneed (talk) 02:32, 17 September 2009 (UTC)

Problems and flagging

Wayyyy too much medical jargon, may have to have a complete rewrite after the content squabble dies down. Once the squabble about how awful or wonderful this is dies down, I expect to come back and apply the editorial hatchet.

  • "local control" is utterly meaningless to mere mortals.
  • The squishy wet details that patient movement can be caused by a large bit of fecal matter moving in the bowel or the bladder filling or any other such biobabble is great for journals, and not for encyclopedia.
  • The whole thing is just massively too long and has waaaayyy too much medico-squabbling.

Putting the subject matter expert flag on the article. - Sinneed (talk) 03:04, 17 September 2009 (UTC)

I have no problem replacing "Local Control" with "cure"AE1978 (talk) 16:33, 17 September 2009 (UTC)


- SinneedI am an expert in this field with deep intimate knowledge of clinical practice along with knowledge of how this technology is implemented and marketed. These edits I have included are from articles written by distinguished and experienced members of the Radiation Oncology field. For example I added a section by Joel Tepper, MD a distinguished member of the community who published an editorial on the topic: Joel E. Tepper, MD, and A. William Blackstock, MD "Randomized Trials and Technology Assessment" Annals of Internal Medicine 151(8) 2009 [5]. Read it. Now follow this link to an article in the Chicago Tribune [6] on the topic. After reading the Chicago Tribune article then go to the Agency for Healthcare and Research Quality, a US government site, and read the press release entitled "Particle Beam Radiation Therapy Promising but Unproven for Treating Cancer"[7] and the article "Technical Brief: Particle Beam Radiation Therapies for Cancer"[8] Tepper points out that new technologies do not fall under the strict guidelines set by the FDA for new drug development. The device industry is less cleanly regulated. So investing in a new expensive technologies such as proton therapy and then showing that they produced negative results has too strong of a negative economic impact to be a realizable business pathway. Many hospitals just keep replacing their research staff until they find someone stupid enough to publish something that forwards their financial goals. The results are biased by financial gain to forward proton therapy down many questionable applications. This is why the Agency for Healthcare and Research Quality has provided funding and an opinion to clarify this. The point is that these are not just my opinions they are those of others within the field.

The treatment of the prostate is a big money maker for these centers as the reimbursement is higher than the payout of equally effective therapies. It is quite possible that these treatment centers are steering patients to this technology to pay the bills. And saying that other conventional therapies are inferior. Do you even know the definition of "conventional radiotherapy"? Is it IMRT? Is it "parallel opposed fields"? Is it "conformal therapy"? Is it "brachytherapy"? Should the article even compare protons with just "conventional therapy"?

The second point is that some edits have been deleted due to their essay nature, high school nature, and now the claim is that the article has too many high brow medical terms. The editors need to make up their minds and quit being antagonistic. At least say what you want and then see if people will follow. Mdphd2012 (talk) 05:35, 17 September 2009 (UTC)

I think mdphd2012 is on the nose in the comment above. These are his opinions, and the fact that others in the field share them does not make them fact or appropriate content for an encyclopedia article. There may be an interesting editorial lurking here, but that belongs elsewhere (the editorial nature of these contributions is highlighted by the extensive references to newspaper/magazine sources rather than peer reviewed papers). Also, there are many in the field that have other opinions (as I know, being an "expert in the field" with nearly 25 years direct involvement in proton therapy). There is also a body of factual clinical data that can be referenced without resorting to opinions.AE1978 (talk) 16:33, 17 September 2009 (UTC)
Please focus on the content, not on the editors. - Sinneed (talk) 13:06, 17 September 2009 (UTC)
What are labeled as my opinions are expressed by others in peer reviewed publications, community articles and government policy. These other opinions agree that proton therapy applications and clinical practice are tainted by a great deal of bias. Remember that careless edits might be responsible for influencing people to choose a therapy for the wrong reasons. It would really be a shame if patients died because of irresponsible edits. Where is the section on the side effects of proton therapy? At least the radiation therapy article has some of these in its prose. Mdphd2012 (talk) 18:36, 17 September 2009 (UTC)
The opinions referenced above have been from editorials in peer reviewed pubs. I agree that these issues may be the source of a good op ed piece, but they don't belong in a encyclopedia article. Also, the references that you yourself cited above take as a given that protons have proved their value in the treatment of head & neck tumors, and are simply calling for randomized studies of the relative efficacy for much more common conditions such as lung and prostate. This is nothing earth shattering, yet you present them as if they cast doubt on proton therapy as a whole. And statements like "Many hospitals just keep replacing their research staff until they find someone stupid enough to publish something that forwards their financial goals" or "It would really be a shame if patients died because of irresponsible edits" are so over the top that they undermine your veracity.AE1978 (talk) 23:14, 17 September 2009 (UTC)
AE1978 -- Still waiting for those edits you promised. Mdphd2012 (talk) 04:43, 18 September 2009 (UTC)
mdphd2012, I thought that the coverage I gave to the realtively weak justification for prostate therapy that I included in the Application section, coupled with the language in that section about how some centers treat a large number of prostates nonetheless, was the edit I promised. I believe it introduces the issue of "profiteering" from prostate in an appropriate manner.AE1978 (talk) 19:43, 21 September 2009 (UTC)
Mdphd2012 -- In very general, WP is in no great hurry. If it were, the table you have added against consensus would be gone, instead of patiently sitting there waiting for other editors to be swayed by your existing arguments, or for you to produce more convincing ones. - Sinneed (talk) 04:49, 18 September 2009 (UTC)
I think the flags need to be restored. wp:sockpuppet or wp:meatpuppet might apply for the Massachusetts ip addresses as well. Also I think this article needs the attention of an unbiased expert in the field. —Preceding unsigned comment added by 24.227.182.26 (talk) 15:48, 25 October 2009 (UTC)
I disagree. I think that the tone of the article is appropriate, and that there is no reason to restore the flags. BTW I am an expert in the field, and I do not believe that I am biased.AE1978 (talk) 18:14, 25 October 2009 (UTC)
I also disagree: the flags are well gone for now.- Sinneed 18:45, 25 October 2009 (UTC)

**HUGE** copy of content from "parent"

A gigantic addition of original research was made today. Please do not re-add it without sourcing, and it is massively too long. If there is that much information, we need a new article called "Side effects of radiotherapy" or some such. And if that much sourced content is added here, I'll create it and move the content too it, and add a summary here. - Sinneed (talk) 03:43, 20 September 2009 (UTC)

Reverted myself and added COI and disputed flags. This does not need to stay up long, it can surely be cited quickly since it was just added, or I will remove it. - Sinneed (talk) 03:55, 20 September 2009 (UTC)

If anyone thinks this should remain without citation, please speak up. If no one but the adding editor supports it, and it remains unsourced, I will kill it under wp:burden and wp:OR (and, really wp:NPOV - that stuff is about radiotherapy) ... the burden is on the editor adding content to show that it belongs if disputed. - Sinneed (talk) 04:14, 20 September 2009 (UTC)
The original side effects that were cited by Sinneed as wp:burden,wp:OR,qp:NPOV, etc. were a cut and past from the radiotherapy article. I do not think this it is original research. I am using material from another article on Radiation therapy and therefore proton treatment. You could try to source off the side effects to another page, but it would not give anybody an opportunity to remove proton side effects that are consider eliminated based on evidenced based medicine reports that will be published in the future. Mdphd2012 (talk) 05:36, 20 September 2009 (UTC)
It is important to understand that these are side effects of radiation therapy, not specific to proton therapy. Indeed, we do need, and have, the side effects for radiation therapy. If there are specific proton therapy side effects, they would belong here.
Not listing the side effect is a misrepresentation of proton therapy. Most of these can be found in any radiation oncology textbook. I have a copy of Hall's book at hand so I am referencing this for convenience. Mdphd2012 (talk) 05:36, 20 September 2009 (UTC)
  • The side effects are listed in the article on radiation therapy, where you improperly copied the content. Our WP license requires that large blocks of content like that not be moved by cut-and-paste. It breaks the content from the edit history. This is a Bad Thing. Please use wp:edit summaries more. Please seriously consider talking about these kinds of things here before doing them. - Sinneed (talk) 05:55, 20 September 2009 (UTC)
  • I also added explicit links to the desired bits in the parent article up near the top of the article here. - Sinneed (talk) 05:55, 20 September 2009 (UTC)
  • If you feel this isn't adequate, I think there is a way to copy the chunks and put in a flag to point from this article to that one for the history. I would encourage fixing the content 1st though, as otherwise we will need to copy it back after it is sourced and otherwise cleaned up, resulting a tremendous mess. Or you can simply revert my edit and keep going, but I think that is a bad idea. - Sinneed (talk) 06:00, 20 September 2009 (UTC)
Everything I do seems to be a bad idea! :) 69.148.237.32 (talk) 06:24, 20 September 2009 (UTC)
I am sorry it feels that way. I don't think it really is. The side-effects-not-mentioned thing is a good and important point.
But I do encourage talking much much more. And please consider (just consider, you are a free person) talking here before:
  • Reinstating an edit previously killed.
  • Making large or contentious changes.

- Sinneed (talk) 06:31, 20 September 2009 (UTC)

  • Here, for example. That is very unkind, and needs a generally wp:reliable source to back it up. It is wp:OR, and seems a bit doubtful, looking at the site. Maybe it is... but must have a source, for sure. - Sinneed (talk) 06:33, 20 September 2009 (UTC)
  • And please, please: log in. - Sinneed (talk) 06:33, 20 September 2009 (UTC)
I think Sinneed's solution is exactly right. Linking to the (very comprehensive) section of side effects in the main radiation therapy article is appropriate.AE1978 (talk) 18:32, 20 September 2009 (UTC)

I added a section on side effects of proton therapy. It is important that people who study this area know the side effects of radiation. Entire books are published on this topic. Radiation protection is an important part of protecting the public and a major role of physicists and medical physicists. Will have to see if consensus wants to argue with this. Mdphd2012 (talk) 23:20, 20 September 2009 (UTC)

You have indeed re-added. - Sinneed 23:41, 20 September 2009 (UTC)
Added offtopic flag and comments to try to be sure no one edits this content here, when it needs to be updated at its subject article Radiation therapy. wp:Consensus is against you. If you truly believe this belongs here, you will need to either seek support or be more convincing. I'll drop the section readded against consensus yet again very soon otherwise.- Sinneed 23:47, 20 September 2009 (UTC)
Idea: I will leave the section head in, and duplicate the side effects bit from the top, with a MAIN flag. This will give the side effects substantial visibility, without going off-topic. I am going to move forward with this. Objections? Other proposed compromise? No response to the last one, just a reversion.- Sinneed 23:57, 20 September 2009 (UTC)
I also dropped the SA... this is way too much "hammering" on the point about side effects and seems to be wp:POINT. Moved the Side effects section up. Hopefully, side effects specific to proton therapy, the subject, will be added eventually by an interested editor. Clearly the long but weakly sourced section at the radiation therapy article will get could use some attention as well.- Sinneed 00:06, 21 September 2009 (UTC)


Yes...

You are entirely correct, and it may be better to say something like "comparatively few" rather than none or few... since there are a VERY large number of protons entering the body. I am going to make that change in both places (still says none in one spot).- Sinneed

The language is important though often a burden to clarity. Maintaining that vigilance can be a burden as well. Unfortunately poor language choice can lead to a misrepresentation of careful scientific practice. Using the phrase "photon" instead of "X-ray" is an example of how poor language choice can mislead a reader to apply broader scientific principles to a specialized application.
In contrast applying the concept of a "photon" shows the equivalence of a small fraction of the x-ray spectrum with gamma ray production. However choosing to use the phrase "gamma ray" contains a statement about the origin of an emitted photon.
In a similar vein just saying that protons stop without some qualifier can mislead as well. Some researchers are applying protons in computed tomography. In proton computed tomography research is based upon the fact that not all protons stop in matter. Mdphd2012 (talk) 17:21, 22 September 2009 (UTC)
Why don't we say "very few" or "almost none", as the number of protons that penetrate more that 2 cm past the B.P. is on the order of 1 in 100,000 (or 0.01%).AE1978 (talk) 13:12, 24 September 2009 (UTC)

Median Survival Time and Cure

Added two sections to motivate the responsible use of the word "cure" by contributors to the article. The clinical definition needs a reference and possibly refinement. Mdphd2012 (talk) 21:23, 22 September 2009 (UTC)

Editing to drive home a wp:POINT is bad. Instead, if you find "cure" misused, perhaps you might:
  • flag it
  • correct it
  • discuss your concern here, staying to the point of the misuse of the word "cure"
- Sinneed 22:05, 22 September 2009 (UTC)
Mere mortals are to be educated by an encyclopedia. As an example "Local control" is mentioned in a previous discussion, so it appears that some editors know better.
"Cure"
* is used in the article.
* is a misnomer and deserves a better choice of language or a clear definition.
* had too many connotations and imprecise denotations to be used in the article without a medical definition.
* has more of a marketing connotation than a pragmatic use.
I choose to the route of definition as it is educational and merits clarity. Frankly the word is used in way too many articles. An interested reader who takes the time to look up a topic in an encyclopedia wants to learn. Mdphd2012 (talk) 00:49, 23 September 2009 (UTC)
Great, so please fix or flag the use of "cure" instead of editing off-topic material into the article to prove some kind of wp:POINT.
This is a wp:coatrack problem (and yes, please give it a read).- Sinneed 01:01, 23 September 2009 (UTC)
Any reason those bits belong in an article about proton therapy?
  • What does the dispute about the meaning of cure tell a person about proton therapy?
  • What does the bit about 5-year survival tell a person about proton therapy.- Sinneed 01:01, 23 September 2009 (UTC)
Anyway, hopefully another interested editor will agree with me and remove these offtopic sections. I have flagged them and support their deletion.- Sinneed 02:09, 23 September 2009 (UTC)
Moved the definitions into a glossary for the page. Also borrowed some definitions from the wiki article on Cancer. Mdphd2012 (talk) 03:25, 23 September 2009 (UTC)
We point at cancer a pretty good bit. wp:NOT a dictionary. Do we need to use "cure" at all? Can't we just fix the use of "cure" to say what it means or not say it at all but instead say... what it means?- Sinneed 03:30, 23 September 2009 (UTC)
Failing communication efforts, I am taking a wild swing at compromise. I have replaced "cure" with versions of either "local control" or "5-year-survival rate", and CN flagged them.
In the same vein, I have added a red link to local control should someone feel there are enough wp:reliable sources to create the article and a need for it.- Sinneed 03:39, 23 September 2009 (UTC)
  • If this is not satisfactory, what changes to the article, other than adding a great deal of content off-topic to proton therapy, would be acceptable?- Sinneed 03:42, 23 September 2009 (UTC)
Just trying to nail down the proper language for "cure" definition. Sinneed had a good first swing at avoiding this issue, but it will need some tweaking. Mdphd2012 (talk) 04:03, 23 September 2009 (UTC)
  • Actually, no. I took a swing at trying to satisfy an editor who will not communicate. Why did you restore a definition for a word not appearing in this article? It adds no information whatsoever about proton therapy, the subject.- Sinneed 04:05, 23 September 2009 (UTC)
  • No explanation as to what these have to do with this article, rather than the article on, say cancer. Removing.- Sinneed 01:42, 24 September 2009 (UTC) Bleh. bad link in the edit summary.- Sinneed 01:44, 24 September 2009 (UTC)
If I am lucky I get to add one or two edits a day. The delete may be premature but can be left out for now. I restored them before I realized that you eliminated "cure" altogether. So perhaps this is the source of the misunderstanding. Mdphd2012 (talk) 04:46, 24 September 2009 (UTC)
Hi Folks, I originally used "Local Control" exculsively in the applications section, and only put in "cure" when another editor pointed out that the general public might not know what local control means (see "problems and flagging" section above). I agree with this, but don't see the need to go into long winded explanations of the terms. I think reverting to a similar usage to what I had before, i.e. ..shown to achieve a higher "cure" (local control) rate than conventional radiotherapy..... I'm going put that language back in (or a variant).AE1978 (talk) 13:12, 24 September 2009 (UTC)

Comparison with other treatment options

I don't think the statement given in the last sentence of the first section- "Current knowledge about how radiation interacts with tumor and normal tissue is imperfect." - is even slightly supported by the references given. The first reference (Tepper) is to an op ed piece that recomends the increased use of radomized protocalls to study new treatment technologies (which is not a problem specific to proton therapy), with proton therapy for lung and prostate as prime examples. The following is a direct quote "Protons are charged particles with a biology very similar to that of x-rays (2). They have been used clinically for more than 30 years in thousands of patients, with minimal unexpected adverse events (3). Although the technology of proton therapy delivery differs from that of x-rays, it is very well defined. The major potential benefit of proton therapy is minimization of irradiation of and toxicity to normal tissues, which may allow higher doses to be delivered to the tumor and thereby increase tumor control. The major problem with proton therapy is that it is far more expensive than conventional radiation therapy." This issue is not presented as a consequence of poor understanding of the underlying physics, as the statement above implies. The second reference is to a dept of health and human services call for a technical brief describing the present state of knowledge about particle therapy and it's relative benefits and risks. No conclusions are drawn in this reference, and it certainly does not support the statement in question. If I don't get any objections, or clarification of this mystery, here on the talk page I will proceed to delete the sentence.AE1978 (talk) 19:08, 24 September 2009 (UTC)

I believe that the statement "Current knowledge about how radiation interacts with tumor and normal tissue is imperfect." is a great qualifier without going into too much depth on this topic. To say otherwise would imply omnipotence. The scientific body of knowledge of radiation effects is certainly sizable, but incomplete.
  • From a physics point of view geometric arguments are a sound approach, along with cross sections and probability of cell kill. Unfortunately physics is best understood as a local problem fixed on shrinking a tumor. Science has not matured to the point of modeling systemic issues. For example alpha/beta ratios are inferred through statistical studies and not first principles. Also, some tumors are even reported as resistant to radiotherapy.
  • The "fuzzy" issue of biological pathways, tumor size, hypoxia, distant metastases, RBE, etc. are not so clean. For example damage to stem cells is one current vogue in biology.
  • The attempt of dose escalation is often a "red herring" argument as it argues local control without concern for systemic issues such as distant metastases. The fact that a patient will die five years later with, or without, dose escalation is one endpoint.
  • Also dose escalation is an attempt to raise the amount of radiation delivered to the patient's tumor which can restore many of the toxic side effects to normal tissue. This also shoves under the carpet the additional dose of external imaging devices which removes the benefit of trying to spare normal tissue.
This also drives home why the phrase "cure" should be avoided because, without a clearly stated definition, it has more connotation than denotation. Mdphd2012 (talk) 21:25, 24 September 2009 (UTC)
None of what you say justifies putting that statement there, as follows;
  • First of all, all of the issues you raise above apply to radiation therapy in general, rather than proton therapy in specific (and no one assumes omnipotence). Thus this statement does not belong in a section about comparing proton therapy to other treatment options. If you want to refer to the limits of our knowledge of radiation effects, put it up where we describe the mechanism action in general (maybe something like "While we don't fully understand the effects of radiation, here is the assumed mechanism......").
  • Second, the references you give do not support this statement (in fact are completely tangential to what you presented above as justification), so it has not met wp:verifiablity test.
  • So, if you can't justify it better than that, please remove it (I don't want to just delete it myself, but I will eventually).
Finally, in response to your ancillary issue about the use of "cure", I originally had "local control", but it was pointed out that many readers of the article would not know what that means. I think that this is a good point, but I am open to any language you would prefer, as long as it doesn't need to be accompanied by a long winded explanation of terms.AE1978 (talk) 17:31, 26 September 2009 (UTC)

Since I haven't heard either any objections to the deletion suggested above, or any better justification for the inclusion of the statement in question, I'm going ahead and removing it.AE1978 (talk) 18:18, 29 September 2009 (UTC)

  • Please mdphd2012, respond to the issues above here on the discussion page, rather than just undoing my edit. If you can't justify the inclusion of this statement, and provide relevent references, it must stay deleted.AE1978 (talk) 21:24, 29 September 2009 (UTC)

In the subsection comparison with surgery there's another bit that should be removed, "The logic for treating common cancers (for example lung, head/neck, etc) with proton therapy is the same as saying that surgery alone should yield high 5-year-survival rates[citation needed] for most cancers, as surgery is the Definitive Local Treatment. Of course, surgery does not - because most cancers spread microscopically very early beyond the tumor ('local') site".. This dosen't make any sense, is un-supported, and just plain should go. I think the section should open with the third paragraph, i.e. "The decision to use surgery or proton therapy (or in fact any radiation therapy) is based on the tumor type, stage, and location. In some instances surgery is superior...". Maybe we should leave the second paragraph about the statistical nature of radiation therapy, but if so it should be at the end. If I don't get any objections, I will make these changes soon, as well as the deletion I suggested above.AE1978 (talk) 18:16, 26 September 2009 (UTC)

I think the caparison with surgery prose , "The logic for treating common cancers... cancers spread microscopically very early beyond the tumor ('local') site"is self evident (though it could be referenced). Basically it says that surgical practice can cut out the cancerous tissue, with margins that extend to disease free tissue, and yet the cancer will re-occur. The cancer re-occurs because the disease is not just localized to that treatment site. In fact diseased cells often exist in other parts of the body. i.e. local control is achieved by surgery yet surgeons still experience cancer metastasizing to other sites. The improved geometric precision of protons is a weightless argument and a "red herring" (see ignoratio elenchi) for common cancers. Claiming superiority of proton therapy over surgery and other therapies is likened to claiming that a sharper scalpel will kill the diseased tissue better. Mdphd2012 (talk) 05:39, 29 September 2009 (UTC)
Sorry, that doesn't fly. The fact that not all tumors are appropriate candidates for radiation therapy is nicely covered in the third paragraph (starting with with "The decision to use surgery or proton therapy (or in fact any radiation therapy) is based on the tumor type, stage, and location. In some instances surgery is superior..."). No one is claiming that proton therapy is superior to surgery or chemotherapy in cases where those treatments are the best option. Thus your argument above is completely beside the point. You seem to keep forgetting that this is an encyclopedia article describing proton therapy, not a forum to argue over the best treatments in specific cases. I now feel even more strongly that we should strike the first two paragraphs of this subsection, the third paragraph alone is just right.AE1978 (talk) 18:18, 29 September 2009 (UTC)
Quoting a 95% rate for local control without presenting the fact that metastatic involvement reduces the overall survival rate is not a practice that I would enjoy encountering as a patient. This is a worthy strategy in marketing the practice of any cancer therapy. It would be more honest to say something like, "For ocular tumors, enucleation (surgery) of the eye has 100% chance of local control. If one is willing to take a 5% hit on one's chance of living longer then hurry up and get proton therapy! With proton therapy you can potentially keep the eye which, if you do not get a cataract from the radiation, looks better than a prosthetic device. With a lot of luck you might even retain some visual acuity, though your visual acuity is expected to decrease over time. And guess what? Based on current medicare reimbursement my proton therapy center and physician can rake in the money. After all proton therapy is a lot more precise than the less expensive plaque therapy, i.e. brachytherapy. Come on down! Your niece and nephew need to pay off their medical school loans!" Mdphd2012 (talk) 03:57, 30 September 2009 (UTC)
Alternatively one could just keep the original content prose "The logic for treating common cancers (for example lung, head/neck, etc) with proton therapy is the same as saying that surgery alone should yield high 5-year-survival rates for most cancers, as surgery is the Definitive Local Treatment. Of course, surgery does not - because most cancers spread microscopically very early beyond the tumor ('local') site" Mdphd2012 (talk) 04:39, 30 September 2009 (UTC)
I'm still convinced that this section should begin and end with the third paragraph ("The decision to use surgery or proton therapy (or in fact any radiation therapy) is based on the tumor type, stage, and location. In some instances surgery is superior..."). The first paragraph is very confusing, and none of the arguments above for keeping it in come anywhere near to swaying me. I'm going ahead and making that change, if any editor wishes to weigh in here on the talk page and give me a reason to restore it please go ahead.AE1978 (talk) 19:05, 22 October 2009 (UTC)

How about adding the information to the "parent" articles

If these concerns are about radiation, they belong there, if they belong anywhere in WP (not supporting or opposing). THEN, either they are called out by the "See also" or "Main article", or *possibly* they need to be mentioned briefly here. We have an entire section for that, and it doesn't seem to be getting any work.- Sinneed 22:36, 29 September 2009 (UTC)

Edit war over "incomplete knowledge"

1st - as written, it belongs in a parent article. 2nd - Knowledge of *EVERYTHING* is incomplete. Knowledge of surgery and its interaction with healthy tissue and tumors is incomplete.

3rd - STOP EDIT WARRING! At least propose new ideas. Neither version is a threat to the encyclopedia. Consider leaving it up and asking "What alternative besides what you have already proposed would be acceptable?" Or trying something of a compromise. Simply reverting between 2 editors is usually pointless and just leads to anger, frustration, and having the article locked or the editors blocked. - Sinneed 03:30, 30 September 2009 (UTC)

Sinneed, I like what you did putting the "incomplete knowledge" statement in the side effects and risks section. Now we need to address the fact that the references given do not actually support or relate to the statement (it seems that we should be able to find a reference that supports such a clearly obvious reality).AE1978 (talk) 17:50, 30 September 2009 (UTC)
In that case, (I haven't fact-checked them), I would say a CN flag is needed just before the refs.- Sinneed 18:21, 30 September 2009 (UTC)
Hi Sinneed, here is a link to the two references, tell me what you think (they're not very long).[9][10]AE1978 (talk) 20:29, 30 September 2009 (UTC)
The Tepper article [11] says, "However, current knowledge about how radiation interacts with tumor and normal tissue is imperfect." Mdphd2012 (talk) 03:52, 1 October 2009 (UTC)
It is a mistake to have moved this quote in the "side effects" section. It implies that the side effects are the only portion of knowledge that is imperfect. Proton therapy knowledge is imperfect and not just restricted to the side effects. Tepper points this out in the article. The article also points out that particle therapy studies do not compare their methodology with the best of radiation therapy. Mdphd2012 (talk) 03:52, 1 October 2009 (UTC)
The AHRQ full technical report is here [12]. The executive report is bland. There is also a release for policy makers [13] and one bullet in the clinical bottom line summary states, "Evidence about the effectiveness and harms of PBRT compared with other cancer treatments is lacking." The full report and the summary for policy makers are accessible from the main page [14] Mdphd2012 (talk) 03:52, 1 October 2009 (UTC)

Proton Pencil Beam

It would be interesting to see a section centered around the proton pencil beam equations in the article. Perhaps AE1978 would take some time off from developing the wiki article Harvard Cyclotron Laboratory and devote some physics talent to this task? Mdphd2012 (talk) 04:27, 30 September 2009 (UTC)

wp:talk - Seriously.- Sinneed 04:59, 30 September 2009 (UTC)

Yes, I had been thinking about putting a section in comparing passive scattering vs active (pencil beam ) scanning as treatment delivery strategies, but I thought that would be a bit too deep & technologicaly detailed for an article of this sort. maybe a brief exposition would be reasonable? I'll see what I can come up with.AE1978 (talk) 17:50, 30 September 2009 (UTC)

With the blocking of the edit warrior...

Do we need the 3 article flags? I propose to delete them in a couple of days.- Sinneed 19:21, 22 October 2009 (UTC)

Is there anything that needs to be done to the article to make removing them uncontested?- Sinneed 19:21, 22 October 2009 (UTC)

I support their removal as well and don't think we need to do anything else to make that reasonable.AE1978 (talk) 17:30, 24 October 2009 (UTC)

I just read this article for the first time. It appears that one or two of the editors are pretending to be Harvard staff. I know quite a quite a few people from this institution and it is my opinion that this is not the work of someone with an Ivy League background. —Preceding unsigned comment added by 24.227.182.26 (talk) 05:45, 25 October 2009 (UTC)

Please see wp:talk. Remove your focus entirely from the editors, and focus on the content. Your comment above is disruptive, and offers no suggestions for article improvement. If abuse of the talk page continues, it can be partially protected.- Sinneed 06:00, 25 October 2009 (UTC)

Comparison with X-ray Radiotherapy

I think Sineed's most recent edits are good, but I think stating that X-rays spare shallower tissues, rather than just skin, is overstating the case. The skin sparing effect only extends a few millimeters in depth. See what you think about my variation. Also, I know this belongs in the "Applications" section, but what does anyone think of eliminating the detailed info about the Uveal Melenoma studies. We don't go into nearly this much detail about any other specific disease ?AE1978 (talk) 21:04, 25 October 2009 (UTC)

Given no objections to the edit/deletion suggested above, I went ahead with it.AE1978 (talk) 13:31, 5 November 2009 (UTC)

MeV

The designation of M in MeV is for "Mega" which is an SI unit equivalent to 10^6 power and coincidentally is the same as one million. The simple thought experiment should clear up any editor's ignorance. If the unit of capacitance is designated as a farad (F) then what is pF? What is mF? What is MF? Now the same is applied to eV. What is peV? What is meV? What is MeV? Mdphd2012 (talk) 04:00, 7 December 2009 (UTC)

Maybe you should look up that which you refer to; SI naming conventions. p, m, and M could possibly mean pico, mili, and mega, respectively, but that's just guessing.— Dædαlus Contribs 04:09, 7 December 2009 (UTC)
The name of the unit is mega. The meaning is million. http://physics.nist.gov/cuu/Units/prefixes.html - Sinneed 04:22, 7 December 2009 (UTC)
"10^6 power coincidentally is the same as one million." The fact that mega and million start with the same letter is a nice mnemonic, but they are trying to tell you that you should use Mega. It is funny to watch people from all over the world (69.117.120.213, 139.222.200.138) try to correct this, and see it "carte blanche" ignored. i.e. wp:consensus was not followed, nor was it brought up for discussion. See wiki electron volt for a self reference. NIST (http://physics.nist.gov/cuu/Units/prefixes.html) makes no mention of the phrase "million" in its article. Mdphd2012 (talk) 19:20, 7 December 2009 (UTC)
Please explain clearly your point in all this. What do you want to happen?— Dædαlus Contribs 10:38, 8 December 2009 (UTC)
mdphd2012 is correct that MeV is the symbol for Mega-electron-Volts, which is equal to 1 million electron volts. However, is is standard usage in both particle physics & clinical physics to use the symbol MeV when denoting energy. I propose we change the sentence to "....produce protons with maximum energies of 70 to 250 MeV (Mega-electron-Volts or million electron Volts)." Does that make everyone happy?AE1978 (talk) 21:15, 9 December 2009 (UTC)
No preference here.- Sinneed 21:17, 9 December 2009 (UTC)
I suggest you be bold and just say "The accelerators used for proton therapy typically produce protons with energies in the range of 70 to 250 MeV." Mdphd2012 (talk) 22:05, 10 December 2009 (UTC)
mdphd2012..please!!!! There is no need to insult people. Obviously if this was one of my papers intended for a journal I would assume that the audience knew what MeV meant. However this is an encyclopedia for general audiences, and I have no objection to pointing out the meaning of the units referred to in layman's terms.AE1978 (talk) 22:47, 10 December 2009 (UTC)

(outdent) - removed personal remarks, orphaning AE1978's response.- Sinneed 06:06, 11 December 2009 (UTC)

Sigh, what about the edit warrior comment? Was that directed at someone? It helps to practice what one preaches. Mdphd2012 (talk) 23:27, 11 December 2009 (UTC)
Tried out the suggestion on fixing MeV. Noticed that the wiki mark-up does not play well with just one letter. I am commenting on this mark-up peculiarity on the off hand chance that it is an unknown behavior. Mdphd2012 (talk) 23:27, 11 December 2009 (UTC)
I put in text that hews a bit closer to the proposed edit above. Thoughts?- Sinneed 23:29, 11 December 2009 (UTC)
Works for me. Thanks folks.AE1978 (talk) 16:41, 12 December 2009 (UTC)
Changed text to omit reference to "million". The logic is that if the unit was "pico", or "kilo", instead of "Mega" then dropping any reference to a "million" would be an obvious edit. Mdphd2012 (talk) 00:14, 13 December 2009 (UTC)
Restored the million. Leaving off the mega would be ok with me.- Sinneed 01:53, 13 December 2009 (UTC)
I say leave it in as well. If the unit was "pico" or "kilo" I would also put in numerical value for general audiences.AE1978 (talk) 13:48, 13 December 2009 (UTC)
Well at least I can say I tried to actually put some semblance of scientific accuracy and genuine logical thought in this article. Hope you editors make lots of money with your proton therapy investments. Mdphd2012 (talk) 03:22, 15 December 2009 (UTC)
  1. ^ Thomas F. Delaney, M.D. Presentation give at PTCOG 47 May 2008
  2. ^ The Modern Technology of Radiation Oncology: A Compendium for Medical Physicists and Radiation Oncologists by Jacob Van Dyk (Editor) Medical Physics Publishing Corporation October 1999 p. 826
  3. ^ "At MGH striking a critical balance - Tough calls as doctors ration proton therapy". The Boston Globe. 2003-12-26. Retrieved 2009-04-16. {{cite news}}: Check date values in: |date= (help)
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