Combined Treatment Modalities for High-Energy Proton Irradiation: Exploiting Specific DNA Repair Dependencies

Abstract

DNA repair deficiencies and genome instability are common features and hallmarks of cancer and are ubiquitously found in the full spectrum of malignant diseases. Heritable DNA repair deficiencies, for example, due to BRCA1 and BRCA2 mutations, and subsequent loss of heterozygosity in mammary, ovarian, and prostate carcinoma, are risk factors for the early development of cancer. Despite their detrimental role in tumorigenesis, these deficiencies also provide novel opportunities for treatment options. Current and future pharmacologic approaches in medical oncology rely on the exploitation of such genetically defined, tumor-specific Achilles' heels and integrate the genetic background of a tumor into the treatment strategy. For example, homologous recombination-corrupted, BRCA1/2-mutated tumors are becoming hypersensitive to inhibitors of an additional DNA-damage-repair mechanism and are successfully treated with respective molecular targeting agents such as PARP1 inhibitors. Patient stratification in radiation oncology today is primarily based on clinical parameters and uses highly sophisticated diagnostic imaging for treatment planning on the individual level. Radiation oncology only minimally takes the genetic makeup of tumors into account, and little attention has been given to the fact that the different modalities of ionizing radiation, such as photon and proton irradiation, may also induce differential damages and biological processes, which might again be influenced by the genetic makeup and mutational status of the tumor. However, radiation oncology is nowadays challenged to understand subtle differences induced by the different qualities of ionizing radiation, and to efficiently exploit and to integrate these differential responses in a personalized treatment approach alone and as part of combined treatment modalities with pharmacologic agents. Here we will review recent insights on the differential DNA damage responses to photon and proton irradiation and discuss their implications for combined treatment modalities with chemotherapeutical agents and small molecular targeting compounds.

Proton therapy for high‐risk prostate cancer: Results from the Proton Collaborative Group PCG 001‐09 prospective registry trial

“…12,21,22 Although in vitro experiments suggest that proton therapy typically yields more DNA damage for the same dose relative to photons, there is no concrete evidence to suggest that biochemical control for prostate cancer is superior with PBT. 8,9 There is, however, a dosimetric advantage with respect to volumetric dose delivered to the bladder and rectum with PBT compared to photon-based EBRT. Therefore, the more likely advantage of PBT to be realized in future clinical trials lies with the toxicity profile.…”

“…[3][4][5][6] Furthermore, preclinical studies have demonstrated higher relative biologic effectiveness (RBE) and more complex DNA damage for proton therapy compared with photon therapy. 7,8 Thus, compared to photon-based radiation, proton therapy might result in enhanced disease control and also fewer side effects in patients with high-risk prostate cancer. Despite these theoretical advantages, the use of proton therapy for prostate cancer remains a controversial topic due to its relatively high costs and lack of level 1 evidence to demonstrate that the dosimetric advantages of proton therapy translate to clinical benefits.…”

“…For the treatment of high‐risk prostate cancer, especially when seminal vesicles and pelvic lymph nodes are included, protons can substantially reduce the volume of normal tissue exposed to low‐moderate doses of radiation 3–6 . Furthermore, preclinical studies have demonstrated higher relative biologic effectiveness (RBE) and more complex DNA damage for proton therapy compared with photon therapy 7,8 . Thus, compared to photon‐based radiation, proton therapy might result in enhanced disease control and also fewer side effects in patients with high‐risk prostate cancer.…”

Three Discipline Collaborative Radiation Therapy (3DCRT) Special Debate: I would treat prostate cancer with proton therapy

“…As a consequence, proton therapy produces greater complexity of DNA damage which requires different mechanisms for DNA repair. This may lead to enhanced disease control compared with photon‐based therapy . In addition, the gene expression responses suggest that protons may result in greater downregulation of certain genes that could impact metastases …”