title: Proton therapy in paediatric oncology: an Irish perspective.
abstract: BACKGROUND
  Proton therapy (PT) is a radiotherapy treatment modality that uses protons, rather than conventional photons. PT is often used in paediatric oncology due to its reported capability to reduce acute and late adverse treatment effects. As PT is unavailable in Ireland, patients are referred abroad for treatment.
  
  
  OBJECTIVE
  To: (1) produce a descriptive study of Irish children referred abroad for PT, and (2) discuss the case for PT in general.
  
  
  METHODS
  A retrospective review of all children referred for PT before October 2015 was performed. Information was gathered regarding demographics, diagnosis, referral timeline, adverse effects attributable to PT, current status and cost. A review of the relevant literature was performed.
  
  
  RESULTS
  Seventeen children treated in Ireland have been referred abroad for PT. The largest number was in the 0-4 year old group. At initial diagnosis the median age was 4.8 years. The average cost per child was €37,312. Two patients suffered disease relapse. Four have encountered PT-related adverse effects.
  
  
  CONCLUSIONS
  Despite the fact that >100,000 patients worldwide have been treated with PT, the level of published evidence to support superiority over conventional treatment remains low. It is debated that randomised control trials in this area would be inconsistent with the principle of clinical equipoise. In contrast, there is a call for level 1 evidence to justify drastic changes in patient care, particularly in light of recent reports of unexpected toxicities. In time, careful evaluation, follow-up and clinical trials will likely support the preferential use of PT in children.
authors.affiliation: St. Luke's Radiation Oncology Network, Radiation Oncology, Dublin, Ireland. karla.lee@rmh.nhs.uk.|Our Lady's Children's Hospital Crumlin, Paediatic Oncology, Dublin, Ireland. karla.lee@rmh.nhs.uk.
authors.forename: K A
authors.initials: KA
authors.lastname: Lee
authors.affiliation: St. Luke's Radiation Oncology Network, Radiation Oncology, Dublin, Ireland.|Our Lady's Children's Hospital Crumlin, Paediatic Oncology, Dublin, Ireland.
authors.forename: C
authors.initials: C
authors.lastname: O'Sullivan
authors.affiliation: St. Luke's Radiation Oncology Network, Radiation Oncology, Dublin, Ireland.|Our Lady's Children's Hospital Crumlin, Paediatic Oncology, Dublin, Ireland.
authors.forename: P
authors.initials: P
authors.lastname: Daly
authors.affiliation: Our Lady's Children's Hospital Crumlin, Paediatic Oncology, Dublin, Ireland.
authors.forename: J
authors.initials: J
authors.lastname: Pears
authors.affiliation: Our Lady's Children's Hospital Crumlin, Paediatic Oncology, Dublin, Ireland.
authors.forename: C
authors.initials: C
authors.lastname: Owens
authors.affiliation: Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), HelmholtzZentrum Munchen (HMGU) Ingolstädter Landstraße 1, 85764, Neuherberg, Germany.|Particle Therapy Department, West German Proton Therapy Centre Essen, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany.
authors.forename: B
authors.initials: B
authors.lastname: Timmermann
authors.affiliation: Paul Scherrer Institute, Center for Proton Therapy, 5232, Villigen Psi, Switzerland.|Hopitaux Universitaires de Geneve, Service de Radio-oncologie, Geneve, GE, Switzerland.
authors.forename: C
authors.initials: C
authors.lastname: Ares
authors.affiliation: Universitätsklinikum Heidelberg, Klinik für Radioonkologie und Strahlentherapie Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.|Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany.
authors.forename: S E
authors.initials: SE
authors.lastname: Combs
authors.affiliation: Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, 32610-0385, USA.
authors.forename: D
authors.initials: D
authors.lastname: Indelicato
authors.affiliation: Our Lady's Children's Hospital Crumlin, Paediatic Oncology, Dublin, Ireland.
authors.forename: M
authors.initials: M
authors.lastname: Capra
mesh_terms: D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007494:Ireland; D008297:Male; D008495:Medical Oncology / Q000379:methods*; D061766:Proton Therapy / Q000379:methods*; D012189:Retrospective Studies
keywords: Ethics; Paediatric oncology; Particle therapy; Proton beam therapy; Research methods