The Beam: New roles for Drs. Weg, Chen and Gillespie, plus a history of radiation

Emily Weg, MD, and Jonathan Chen, MD, PhD, are two of our esteemed proton therapy experts at Fred Hutchinson Cancer Center – Proton Therapy. Both are highly respected among patients as well as staff. Weg specializes in treating prostate cancer, and Chen focuses both on prostate and ocular cancers. Both have also recently been promoted to new positions within Fred Hutch. 

Emily Weg, MD, associate medical director, Fred Hutchinson Cancer Center – Proton Therapy

As of June 1, Weg became the associate medical director at the proton therapy facility. She is taking on this role in addition to the many committees she serves on, including the Radiation Safety, Clinical Trials, Clinical Competency and Program Evaluation committees. On the national level, she is a member of the ASTRO GU Scientific Track, American Brachytherapy Society Education Committee, SWOG Radiation Oncology Research Support Committee, PCCTC/PCF Genetics Working Group and Bladder Cancer Advisory Network Scientific Review Group. Weg is also the site director for the Fred Hutch Residency Program at the South Lake Union Clinic. 

“We approached Dr. Weg for this position because she has always shown the highest level of commitment to patient care and has built strong relationships with the team at the proton facility. She is an excellent leader and communicator, and we are confident she will excel in this role,” says Proton Therapy Medical Director Jing Zeng, MD.  

As associate medical director, Weg will assist Zeng in making sure the facility functions seamlessly for both patients and staff. She will think strategically about growth while maintaining the high standard of quality of care we provide our patients. 

“The proton therapy facility is a treasure. It’s so patient-centric, and we have a great work culture. I was thrilled by the opportunity to be part of its leadership. I look forward to working with Dr. Zeng and to be able to contribute to keeping the facility the phenomenal patient experience that it is,” says Weg. 

“Proton therapy is a rare resource that leverages the physical properties of particle beams and can offer superior treatment options for patients. Since there are so few centers, we need to contribute as much as we can to patient care.”

Weg values strong communication with both patients and staff. She is working to optimize communication and workflows among staff with proton treatment planning and with nursing and physician teams, which will translate into even smoother patient care.

Jonathan Chen, MD, PhD, medical director, Fred Hutch at UW Medical Center – Northwest

On July 1, Chen was promoted to medical director of the radiation oncology department at Fred Hutch at UW Medical Center – Northwest, which offers standard photon radiation therapy on the same campus as the proton therapy facility. He’s excited to be able to contribute to his passion for clinical care in an administrative role and hopes to expand the Northwest clinic from a community site to a primary site of Fred Hutch. Chen feels very honored to have been asked to take on this role. 

“Dr. Chen is a perfect example of a physician who ‘puts patient first,’” says Ramesh Rengan, MD, PhD, chair of the department of radiation oncology. “He has built a strong reputation for providing the highest quality care in his clinical specialties of genitourinary malignancies, ocular melanoma, and proton therapy. His dedication to improving the patient care experience for all cancer patients at Fred Hutch makes him an ideal candidate to lead the radiation oncology program at the Northwest clinic. We are fortunate to have his leadership in our department.”

Although his new responsibilities will divide his time between the proton therapy facility and the Northwest clinic, Chen has set in motion ways to make sure he is able continue treating many proton patients. One part of his vision as medical director is to develop a unified strategic mission for both photon and proton therapy and develop a powerhouse cancer center for care and research. Currently, the Northwest clinic offers no radiation clinical trials, but Chen aims to change that.

“I try to treat my patients as I would want to be treated,” says Chen. “In taking on this administrative role, I aim to work on the same principles, so that everything I do — from budget discussions to technological implementations — will be with the highest-quality patient care in mind.”

Chen also serves on a number of committees, including the GU Leadership, Residency Selection, Clinical Productivity, Program Evaluation and Faculty Search committees. On the national level, he is a member of ASTRO, ACR and PTCOG-NA as well as an associate editor for Advances in Radiation Oncology. He is also the Fred Hutch Residency Program Site Director residency program site director at the proton facility. 

Both Chen and Weg have young families. Weg feels she is most productive when she’s busy, although sometimes it can be a challenge to juggle work, her many committees and her family responsibilities as a mother of young children. 

“Sometimes everything is in balance, and sometimes it isn’t, but I feel passionate about everything I’m involved in,” says Weg. “I value my family time, and I value my patients. I try hard to get to know every patient on a personal level, to know their preferences and priorities, and to match those with the most individualized treatment recommendations.” 

Chen says he is looking forward to the challenges with his new role. “Work-life balance is very important to me, and I have a two-year-old at home,” he says. “Just like becoming a father developed a lot of different skills, this new role is definitely a big change, but will allow me to build and flex some new muscles. In the end, what I’m most passionate about is improving our care of patients, and I think this will give me an opportunity to do that in a different way.”

Please congratulate Weg and Chen the next time you see them. 

Meet our newest breast cancer specialist, Dr. Erin Gillespie

In winter 2022, Erin Gillespie, MD, joined the multidisciplinary breast cancer team at Fred Hutch which provides care for patients at the proton therapy facility. Gillespie is a physician—scientist, which means she does extensive research in addition to seeing patients in clinic. 

Her research focus is on understanding variation in the quality and types of cancer treatments people receive. She first became interested in this area when her mother was diagnosed with breast cancer while living in Anchorage, Alaska. At that time, her family felt that traveling to the “lower 48,” or the contiguous U.S., was necessary to receive the best radiation treatment. While they were fortunate to be able to relocate for radiation, they had little information to base the decision on that affected their lives for several weeks. Gillespie wants to make sure that all patients have equal access to the best treatments, including confidence in local treatment, when possible — regardless of where they live.

“Finding the right treatment for my patients is one of my main care philosophies,” explains Gillespie. “My approach to patient-centered clinical care is to understand the patient’s perspective and try to minimize the burden of treatment through the use of telemedicine and shorter treatments when we can. We know from prior clinical trials that each clinic and treatment visit can contribute to a patient’s fatigue, ability to meet family needs and associated travel costs. It’s important for me to understand from their perspective what I can do to help with that.”

Gillespie’s research also focuses on identifying treatment approaches that minimize both short-term and long-term side effects of cancer treatment. In this regard, proton therapy has promise for patients with advanced breast cancer, since radiation treatment can have long-term effects on the heart. 

“At Fred Hutch, we are enrolling patients in a randomized trial that compares standard photon radiation and proton radiation therapy,” says Gillespie. “Proton therapy is an important treatment option for potentially reducing radiation to the heart and lessening long-term cardiac effects. Evidence from clinical studies is necessary to convince insurance carriers that proton therapy is better than standard photon radiation in these cases, so we encourage and support patients with advanced breast cancer to enroll in the trial, which is called RADCOMP. Patients sometimes have preferences for one treatment over another, or skepticism about clinical trials in general. However, it is very important that patients participate in trials in order to determine if such specialized treatments are safe and effective so that we can advance cancer treatment, and ensure better outcomes, for all patients with breast cancer.” 

Generally, breast cancer patients with lymph node involvement, and for whom radiation is recommended, are eligible to enroll. It is always a patient's decision on whether or not to participate in a clinical trial.

Gillespie is glad to be back on the West Coast after having worked for five years at Memorial Sloan Kettering Cancer Center in New York City. She and her family love to spend time outdoors, particularly skiing and hiking. Because it serves a large geographic area as well as a diverse patient population, Fred Hutch and UW Medicine is the ideal place for Gillespie to provide clinical care and conduct research that expands access to high-quality, patient-centered care and innovates on the way patients experience cancer care.

The path to proton therapy

Proton therapy is a precise, effective cancer treatment and an important resource for patients and caregivers in the Pacific Northwest. The ability to offer this type of radiation is the result of decades of work by scientists across multiple disciplines. Here’s a look at what had to happen to make proton therapy available in our region today. 

Earliest history of radiation

No type of radiation therapy would be possible without the discovery of X-rays by Wilhelm Röntgen in 1895. This discovery was met with extreme interest in the scientific world, and a number of lines of research began. Within just a month of Röntgen's publication, the medical community was using X-rays to help surgeons. For his work, Röntgen was awarded the first Nobel Prize in Physics in 1901.

Scientists soon discovered that prolonged exposure to X-rays had noticeable effects, such as inflammation and tissue damage. Léopold Freund and Eduard Schiff, intrigued by this, suggested that X-rays could be used in the treatment of disease. As early as 1896, a physician in Chicago used X-rays to treat a woman with recurrent breast cancer. Shortly after that, journals had published many successful treatments of different types of skin issues with X-rays. However, the scientific community still didn't know what exactly it was that was helping. Was it the electrons or the ozone they created? In 1900, an Austrian radiologist named Robert Kienböck demonstrated that it was the X-rays themselves.

Soon the field of röntgenotherapy was born, mainly to treat lupus, carcinomas, leukemia, skin problems, such as eczema, and bacterial diseases such as tuberculosis. 

To treat patients with X-rays, scientists used cathode tubes to accelerate electrons. When the electrons hit metal at the end of the tube, they created X-rays, which were then directed through the skin. However, when used to treat deeper-lying tumors, the X-rays deposited too much radiation in the skin, leading to unwanted side effects. Scientists experimented with cobalt and other materials to create higher-energy electrons, which, in turn, created higher-energy X-rays. To put early X-ray acceleration into perspective, the earliest tubes could create 125,000 volts. Modern machines generate 18 million volts. 

Today, it’s still the case that, due to the nature of X-rays, most radiation is deposited at entry into the body, and decreases as it passes through the tissue. To counteract this, physicians now often use multiple rays that overlap only at the tumor site. 

Discovery of protons and their unique superpower

Around the turn of the 20th century, a series of discoveries helped people understand the various components of atoms. J.J. Thompson first discovered the positive and negative charges in atoms, leading to the discovery of electrons. A few years later, Ernest Rutherford discovered the atomic nucleus and the positively-charged particles they contained — protons. 

William Henry Bragg found that charged particles in the atom lose energy as they travel through matter. For protons, this energy loss happens suddenly, before it comes to a stop. Bragg discovered this phenomenon in 1903, which we now call the Bragg Peak. This discovery showed great promise in reducing potential radiation side effects if used to treat conditions underneath deeper layers of healthy tissue. American physicist Robert R. Wilson was the first to suggest using protons for radiation therapy in a paper published in 1946. Berkley Radiation Laboratory, where Wilson had studied under Ernest Lawrence (see below), delivered the first proton therapy treatments for cancer in 1954. We now understand their importance in treating tumors that are close to vital organs.  

Cyclotron 

A cyclotron is a type of particle accelerator that was invented by physicist Ernest Lawrence in 1930 at the University of California, Berkeley. Cyclotrons can accelerate protons to two-thirds the speed of light. Before cyclotrons, particles such as protons were accelerated in linear accelerators called linacs. Linacs cost more to operate and require more space than cyclotrons, which accelerate particles in a spiral path, resulting in both space and cost savings. 

Imaging

The first treatments using radiation were done without any X-ray imaging. Physicians made the margins around a tumor sufficiently large to make sure that the cancer was completely treated. External marks placed on the patient’s skin defined the area to be treated, and patients were immobilized using various accessories to ensure they were positioned properly every day. Even today, imaging is not always necessary, such as when the tumor lies on the skin.

In 1971, engineer Godfrey Hounsfield and physicist Allan Cormack invented the computerized tomography (CT) scan, which combines a series of X-ray images taken from different angles around the patient’s body and uses computer processing to create cross-sectional (slices) images of the bones, blood vessels and soft tissue. Shortly after, physicians treating patients with protons began using the scans to determine the precise location of the tumor as well as the necessary beam strength. CT scans were therefore crucial to the development of proton therapy.

Today, imaging is used in two ways for radiation therapy: CT-based imaging that physicians use to plan treatment and small amounts of X-ray imaging to position the patient precisely for treatment each day. 

Treatment planning software

Treatment planning systems are essential for all types of radiation therapy. These systems are highly sophisticated computer programs developed by physicists. A proton beam coming from the cyclotron has many parameters that can make cancer treatments more accurate and effective by tweaking them to ensure maximum damage to cancer cells and minimized harm to healthy cells. A treatment planning system allows adjustments to the parameters and sends them to a proton therapy delivery system for optimum treatment.

Many of the early proton therapy centers had to create their own treatment planning software because commercial software did not yet exist. Some centers continue to use non-commercial software written by their own physicists. 

FDA approval

Proton therapy has been used in research settings since the 1950s. Before it could become commercially available for patient treatment throughout the U.S., it had to get approval from the Food and Drug Administration. 

Any new device or procedure needs an investigational device exemption that allows scientists to use the investigational device in clinical trials — first in animals and, eventually, in humans — to collect safety and effectiveness data. There must be enough evidence that a device is safe and effective. Even after FDA approval is granted, operators, manufacturers and physicians are required to track and report operational data about the facilities and their patients. FDA approval was obtained for proton therapy in 1988.

Cost of centers

In the beginning, only large, well-established hospitals could afford to provide proton therapy because of the high cost of construction and equipment. We’re fortunate that Fred Hutchinson Cancer Center had the foresight, interest and ability to open a proton therapy center in 2013. Today, many hospitals and treatment centers are opting for a one-room proton treatment facility as an affordable way to offer all the advantages of proton therapy. In addition to the physical construction, proton therapy needs collaboration between many different professional groups, including engineers, scientists, physicists, physicians, treatment planners (dosimetrists), nurses, radiation therapists and other support staff. 

Ongoing innovations

Physicists and physicians are by no means done understanding all that radiation and the therapeutic effects it has to offer. Research is ongoing, including here at Fred Hutch, to see how radiation can be used more effectively and with minimal side effects. This includes finding ways to be as precise as possible in its delivery, shortening the course of treatment when possible and elevating the dose. 

Pencil beam scanning (PBS)

PBS was first introduced at the Paul Scherrer Institute in Switzerland in 1996. Using magnets to direct the proton beams, PBS “paints” the tumor with a lot of very thin, very exact beams of protons that have sharper Bragg peaks. The beams are accurate down to millimeters and do not require the apertures and compensators of the passive scattering method of proton therapy delivery. PBS sends very fast pulses of protons to the tumor until it is completely treated. The proton beam’s position and intensity can be controlled, which can lower the amount of radiation to healthy tissue even more than traditional proton therapy.

FLASH proton therapy

FLASH radiation therapy is another innovation currently being researched at Fred Hutch and other facilities across the globe. FLASH uses ultra-high-speed radiation (which gives radiation 100 to 1000 times faster than usual) to decrease side effects from radiation treatment. Although there have been some promising results, researchers still don’t know why or how FLASH reduces side effects, but one theory is that the ultra-high rate of radiation delivery depletes oxygen in the healthy surrounding tissue, which protects it from radiation. In 2022, a non-randomized clinical trial involving patients at Cincinnati Children’s/UC Health Proton Therapy Center found that FLASH proton therapy was safe and as effective as standard treatment. 

Many events and discoveries had to fall into place to make proton therapy possible and available to a wide number of people. Thanks to these scientists’ excellent research, discovery and exploration, we can now treat many solid tumors with minimal side effects safely, effectively and with more precision than traditional radiation methods. Proton therapy has made radiation treatment safer for children, who are more sensitive to the effects of radiation; allowed physicians to treat patients who have already had radiation therapy; and minimized the chance of developing secondary cancers and other side effects. 

We are proud to have treated more than 4,000 patients at the proton therapy facility and grateful to offer this treatment option in the Pacific Northwest. 

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