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Feature Radiotherapy

How NHS investment in proton beam therapy is coming to fruition

BMJ 2019; 364 doi: (Published 11 February 2019) Cite this as: BMJ 2019;364:l313

Only Proton Collaboration can cut Costs and Increase Clinical Value

Dear Sir,

This article continues the important debate on the indications in which Proton Beam Therapy (PBT) can offer benefit over conventional radiotherapy.

As reported, there is evidence that PBT was oversold in the USA and this needs to be avoided as capacity for PBT grows here. The Rutherford Cancer Centres (RCC) in the UK, maintain that PBT should only be used in certain specific situations where there is clear dosimetric benefit. Indeed, we have turned down over 50% of patients referred for PBT, recommending conventional therapy in situations where the dose to critical tissues surrounding a cancer cannot be reduced by protons after double planning. Each patient is peer reviewed by our colleagues in University of Pennsylvania, one of the largest proton centres in the US, which uses similar equipment.

For decades, the UK has been left behind in its provision of PBT. Most Western European countries have had operational sites for several years. Their forward plans now call for 10-15% of radical radiotherapy to be delivered by PBT (1). The NHS plan is for less than 1.5%. This figure may well have been determined on availability and affordability but now needs review. Our first centre is open in Newport, South Wales and treating adult Welsh NHS patients following a rigorous external inspection process which included a leading US paediatric radiation oncologist. Further sites will open shortly in Northumbria, Reading, Liverpool and London.

In its own strategy document from 2012 the Department of Health document (2) states:

“There are 1500 patients in the UK per annum (including approximately 250 paediatric patients) for whom PBT is the treatment of choice with clear evidence of health gain. The cancer indications where the experts’ review of evidence identified that patients would benefit from PBT, show benefits in terms of reduced side effects, increased cure rates and reduced morbidity.”

A further document, Radiotherapy Services in England in 2012 (3), added:

"A strategic business case has been approved and there are now plans to develop a National Proton Beam Therapy Service in England delivered on two sites, the Christie and UCLH, from the end of 2017. The national service will treat up to 1500 patients annually."

Yet, despite this commitment, due to delays, no patients were treated at NHS facilities domestically prior to December 2018, and less than 250 patients were sent overseas. It is not clear what provision was made for the remaining 1250 patients who might otherwise have benefited from PBT funded by the NHS.

Meanwhile, the maximum capacity of the NHS centre in Manchester is currently 750. Whilst this is to be applauded, many NHS patients will no doubt continue to be sent overseas due to the current under-provision of PBT within the NHS.

The future is now positive for PBT in the UK, and private and public providers must cooperate as closely as possible to enhance patient outcomes. This would result in better sharing of data, research and clinical trials and could immediately end the costly and disruptive process of sending patients abroad.

Yours sincerely,
Professor Karol Sikora

1. Crellin AM, Burnet NG. Proton beam therapy: the context, future direction and challenges become clearer. Clinical Oncology. 2014 Dec 1;26(12):736-8.
2. National Proton Beam Therapy Service Development Programme (Internet). Department of Health. 2012 (cited 15 February 2019). Available from:
3. Radiotherapy Services in England 2012 (Internet). Department of Health. 2012 (cited 15 February 2019). Available from:

Competing interests: I am Chief Medical Officer of Rutherford Cancer Centres.

18 February 2019
Karol Sikora
Chief Medical Officer
Rutherford Cancer Centres