The Beam: Consult process for proton therapy, secret lives of staff and meet the newest radiation therapist

Consult process for proton therapy

When proton therapy is first recommended for patients by their oncologist or primary care physician, or when a patient has learned about proton therapy as a treatment option another way, the first step at Fred Hutch Cancer Center – Proton Therapy is to get a consultation with one of the providers. 

The path may look slightly different, depending on what cancer type or tumor a patient is diagnosed with.

“We generally have two paths: the prostate path and the path for all other cancers,” said Candice Day-Darby, patient access lead for proton therapy. “That is because most non-prostate cancers are more complex and candidacy can vary wildly.”

Prostate cancer

A prostate cancer patient’s path for a consultation on protons usually begins with a phone call. The Fred Hutch patient access team will gather all relevant information from the patient such as insurance, demographics, emergency numbers, health history and medical records. There are only a few cases when proton therapy is not an option, such as when a patient has had a double hip replacement, or when they have advanced metastatic disease. Within two to three weeks after the phone call, the patient access coordinator will schedule a consult with a radiation oncologist. Prior to the consult with the radiation oncologist, the team will gather all medical files and imaging done to date.

“Generally during a consult, I go over the medical records with the patient and gather all the information I need to guide a decision,” said T. Martin Ma, MD, PhD, one of Fred Hutch’s radiation oncologists who frequently treats prostate cancer patients with protons. “I need to know about medical conditions that might affect the treatment plan. What are their urination symptoms? Do they have support systems or come from far away?”

Ma and his colleagues can then better discuss what options are on the table. The radiation oncologist will typically speak to all recommended radiation options, which may include proton therapy, brachytherapy or conventional radiation. They may also discuss a surgical option. Once all the options have been reviewed, the physician and patient will decide on the best path for the patient. 

“There are pros and cons to each,” said Ma. “It depends on what risk groups they fall into. Sometimes I can offer a proton radiation course that involves treatments every day for four to five-and-a-half weeks, other times I can offer five-treatment [photon] stereotactic body radiotherapy. If a patient is a candidate for conventional radiation, they are usually also a candidate for protons.”

However, sometimes proton therapy or radiation is not an option, such as when a patient has ulcerative colitis — because radiation might cause a flare up — or when the urethra is too obstructed. Ma and his colleagues generally suggest the patient then speak further with a surgeon. 

Other tumors

For patients with more complex cancers, the process starts with a case review of medical records.

“This might take a week, longer for international patients,” said Day-Darby. “A case review means that the radiation oncologist will look at the patient’s history, imaging and other relevant information to see if they are a candidate for protons.”

If they are not, the patient access team will notify the patient and convey any recommendation the physician had for next steps.

If a patient is a candidate for protons or at least radiation, the patient access team will schedule a consult as soon as possible.

“Patients frequently come in with a preconceived idea about protons, and we often discuss the benefits and risks of it as well as alternatives,” said Annemarie Shepherd, MD, medical director of the proton therapy facility and a thoracic cancer specialist. “Often candidates for proton therapy can be the most challenging cases — they have advanced disease or a large treatment field, or they have received previous radiation to the same area. So, there can be some serious risks and it can be a very involved, personal discussion. Though it can often be beneficial in terms of sparing healthy tissue, proton therapy is not a magical solution. And if conventional radiation or even surgery is better suited, I will discuss that with patients, too.”

After this discussion with the radiation oncologist, the patient and physician will decide on the treatment path and next steps. Sometimes a patient needs more time to consider pros and cons, and sometimes logistics such as insurance and travel can pose a challenge. The provider will discuss any risks in delay of treatment.

The patient access team will also work with patients on any financial options, from insurance details or appeals to self-pay options and financial assistance through Medicaid, Fred Hutch or outside sources.

There are only a few variations to the consult process.

“Most patients will be seen at the proton therapy facility or virtually, but head and neck patients are seen at UW Medicine – Montlake, in their special exam rooms that are equipped with the correct implements to determine candidacy,” said Day-Darby. “Pediatric patients — because of our close relationship with Seattle Children's and other pediatric facilities — generally do not need a case review and can be scheduled immediately for a consult once referred. And ocular patients can only be consulted when they have been referred by one of four partnering ocular oncologists in the region.”

These ocular oncologists know exactly when protons are indicated, allowing for patients to be scheduled immediately.

Our radiation oncologists try to answer all questions and explain all options so patients can make the best-informed decision that takes into account whether insurance or self-pay are barriers.

To request a consult, please use this patient web form. To request a consult for your patient, please use this provider web form. 

Secret lives of staff: Proton therapy staff share what gives them focus and happiness outside of work

The staff at Fred Hutch Cancer Center – Proton Therapy have been frequently praised by physicians and patients alike for their dedication, diligence, friendliness and empathy. Many of them have amazing skills and hobbies outside of their work at Fred Hutch that patients might not be aware of.

Nely Ramirez is a radiation therapist at the facility and delivers treatment to patients every day. She is also a bodybuilder and got into the sport thanks to her grandmother.

“During my childhood, she would race and play arm wrestling games with all her grandchildren. It motivated me to be strong and fast like her. As I started working out, the joy and fulfillment I experienced not only uplifted my spirit but also helped me align my mind and body in a way that feels truly harmonious,” said Ramirez.

For the past seven years, Ramirez has been committed to weightlifting and cardio and she finds each moment has been an opportunity for growth and transformation in life. She begins her routine with meditation and prayer to center and align her intentions, which help her push herself to new limits.

Ramirez has competed in bodybuilding in the past, winning third place in a national women’s competition. Today, her focus is on personal growth.

“My only competition is with myself now,” she said. “I want to be stronger or more agile than before, and I embrace the process rather than the outcome. Bodybuilding brings balance and readiness. It equips me to be present for the people in my life, allowing me to serve and connect with others more fully. Physically, I feel stronger. Emotionally, I feel empowered, and mentally, I find clarity and purpose.”

Alex Egan, PhD, is a medical physicist at the proton therapy facility, calculating the angles and doses of proton energy required to treat a tumor.

He races motorcycles in the summer and does ice climbing in the winter. "The rest of the time, he is just a mild-mannered physicist,” said his colleague, Charles Bloch, PhD.

Egan got interested in motorcycles about four years ago, when he bought his first bike on a whim. Since he had never ridden a motorcycle before, the salesperson suggested he take it to the local racetrack to help him become a better, safer rider. Three months later he was “chasing lap times” at the racetrack with his second, track-dedicated race bike.

 “As someone who has always chased extreme experiences, I don't think anything compares to riding a modern sport bike on a racetrack,” said Egan. “The combination of thrills and the risk of crashing forces me to focus at a level that’s hard for me to describe in words. All thoughts other than the technical aspects of manipulating the bike are completely gone.”

For Egan, it’s both a life-perspective reset and a mind-clearing meditation every time he goes out onto the track.

“Maybe that morning I was ruminating about something at work, but at the end of the day, I'm feeling grateful to be alive and that the sky is blue,” he said.

His first year, Egan participated in "track days" at three local tracks where casual riders practice, but as he gained skill, he joined a local racing club. For two years, he raced as a novice in the Washington Motorcycle Road Racing Association (WMRRA) and last summer earned his expert racing license.

“Track racing is actually very technical, so there is always something to learn about or improve upon,” said Egan. “In the beginning, you're just learning the limits of your bike and memorizing the ‘race line’ for a given track. But in time you learn that variables such as track temperature, tire pressures and different suspension settings can change outcomes. The trick is figuring out how to keep the throttle completely open for as long as possible, without losing tire grip and crashing.”

Egan explained that crashing is an integral part of track riding, but riders use a specialized full-body, padded-leather suit and a helmet. The tracks are designed with flat grass or gravel runs after corners, and it is surprisingly rare that riders are seriously injured if a crash does occur.

“I would say motorcycles equal happiness," said Egan. "They really do.”

Blake Webb, a dosimetrist, creates treatment plans for patients every day. He calculates dose distributions, working to minimize exposure of healthy tissue to radiation. When he’s not working, he has been rebuilding his 100-plus-year-old house in West Seattle.

“The addition took nearly 10 years, as we literally lifted the house and more than doubled the footprint,” said Webb.  “I did about 75% of the work myself by hiring workers smarter than me and following them around learning every step of the way. Once I felt confident in completing a portion, I would do so myself, sometimes with the help of YouTube or phoning a friend.” 

Webb has always enjoyed carpentry, starting as a kid and improving through mentors and woodshop in middle and high school. The hardest task was setting the foundation forms, which he described as heavy and awkward. Sheetrocking and mudding were tedious, but he enjoyed the finish work, specifically trimming and molding.

 “With all the devices and distractions in our world today, working with my hands gives me something tangible to delve into and focus on,” he said. "The fruits of my labor provide instant gratification and the grind and grit it takes to figure something out gives me confidence to do hard things, even when I am unsure of something.”

Webb still has plenty of work to do on the house. He plans to take down some interior walls to open the space up. With such an old house, there are always things to touch up.

“There have been many anxious moments over the years — blood, sweat, tears and failures,” said Webb. “It hasn’t been easy, but these types of tasks have helped me become a better dosimetrist. When tough plans come across my desk, I know that with hard work and by reaching out to colleagues, we can work together and achieve success.”

Another dosimetrist, Gabriel Ayala, collects rare books, especially Stephen King novels.

“Knowing a book’s rarity comes with experience and book education,” he said. “Book publishers are quite inconsistent in how they denote first editions, first printings, and so on, so it can be quite confusing.”

Supply and demand play a role in what makes a book rare, not necessarily the number of copies out in the world. Ayala has one book that had a print run of only 26 books as well as some that had print runs of only 100, which are generally part of signed limited releases.

For example, over 10 years ago, Sunup Press released a 300-book signed special edition of Stephen King’s “Misery.”  They were available for $300 a book and sold out within minutes. He was able to get one of them. Today, this book sells for $8,000.

Ayala sources books online from various collections around the country. Sometimes he’ll find one in a used bookstore, which is always exciting, he said. Checking out Powell’s Rare Book Room in Portland is on his bucket list.

Most of his books, though rare, are not old. His oldest ones are from the 1970s.

“It helps not to have to do anything special to preserve them. I do keep them away from humidity and direct sunlight. Humidity can cause mold and sunlight fades the dust jackets,” he explained.

Ayala collects a few rare books from other authors, but his favorites are his Stephen King books, especially the Dark Towers series. He’s currently looking for an advance readers' edition of “The Gunslinger.” He’s also recently become interested in Cormac McCarthy’s older original hardcovers. 

Meet radiation therapist Paul Lee

Fred Hutch’s newest radiation therapist, Paul Lee, was born in Honolulu to a pastor and a nanny and was raised mostly in southern California and Washington. Lee started his career as a legal assistant handling personal injury lawsuits. However, he decided to enroll at Bellevue College to pursue his interest in health care as a radiation therapist. His younger brother is now following suit. 

“As a radiation therapist, I set up patients for treatment, take X-rays to position them correctly, and deliver the treatment that is planned by the radiation oncologist, physicists, and dosimetrists,” Lee explained. “I also review treatment plans and schedules before a patient begins treatment.”

Because the human body is very flexible and mobile and can look different every day, radiation therapists take X-rays daily to confirm that the patient is in the correct position. In addition, they conduct quality assurance checks every morning before treatments.

The radiation therapy program can be a two-year associate’s degree or a four-year bachelor’s degree. Part of the educational program involves working in clinics and gaining experience under supervision of current radiation therapists. There are also continuing education requirements that have to be fulfilled every two years.

Lee learned about proton therapy during one of his program’s clinical rotations. He decided to apply to Fred Hutch after graduation because he liked the team and work culture at the facility.

“I most enjoy getting to know the patients and working with my colleagues,” he said.

As a radiation therapist, he typically sees the same patients for many weeks.

“It’s bittersweet when patients finish treatment because I will miss them, but I’m also happy that they’re on their way to recovery.”

Outside of work, Lee enjoys spending time in nature. “My favorite spot to see the sunset is Richmond Beach,” he added.

Lee also likes to play video games with his brother, hang out with his fiancée, family and friends and practice his karaoke skills. His favorite song to sing is “Beyond the Sea” by Bobby Darin.

Next time you see Lee at the facility, let him know your favorite karaoke song.