Use LET, RBE and alpha/beta to decide when protons beat IMRT
Protons cost more than shaped X-ray beams. They are worth it when the extra punch where the beam stops, and the missing exit dose, widen the gap between killing the tumour and harming late-reacting tissue: an alpha/beta and RBE question, not a machine question.
Overview
Adult proton versus photon randomised trials have mixed toxicity results and scarce survival differences. Plans are still reported at a constant RBE of 1.1. The biological reason protons could win is site-specific: a low-alpha/beta tumour next to a low-alpha/beta late organ, plus high linear energy transfer at a distal edge that can be kept inside the target and off the organ. That predicted window should be written down before the trial reads out. The coverage-with-evidence idea asks payers to fund the trials; this idea asks the trials to test the radiobiology, not only the machine.
- Surgery and radiotherapy cure most, get least · Surgery and radiotherapy cure more people than drugs do, but attract a fraction of the research investment.
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