The Beam: Protons for head and neck cancers, a look at our RTTs, meet Angelle Schilling

When are protons are typically preferred in treating head and neck cancers?

While there are general principles, the decision to treat head and neck cancers with proton radiation at Fred Hutch Cancer Center – Proton Therapy is made on a case-by-case basis.

Head and neck cancers include those located in the upper aerodigestive system (eyes, ear, nose, throat, sinuses, mouth, tongue, tonsils); on the skin of the face, scalp and neck; and on the salivary glands, thyroid and skull. These tumors are particularly close to sensitive and vital organs such as the brain, spinal cord, eyes, ears, taste buds and more.  

“The number one benefit of proton therapy is the lack of an ‘exit dose’ of intermediate- to low-dose radiation delivered to healthy tissue beyond the tumor,” said Fred Hutch radiation oncologist Upendra Parvathaneni, MD, FRANZCR. “For example, a tumor in the ear is very close to the temporal lobe of the brain. Protons can often be a good choice because we can deliver less radiation to the temporal lobe, which plays a role in managing emotions, processing information from your senses, storing and receiving memories and understanding language.” 

On the other hand, when healthy tissues are too close to the tumor, they cannot be spared from high doses of radiation whether you use proton therapy or standard X-ray therapy. Both are effective at destroying tumor cells and so there is no clear advantage to protons. 

“We have to think about both the tumor and the surrounding normal tissues,” said Jing Zeng, MD, Fred Hutch proton therapy medical director.  “Sometimes proton radiation can help spare a lot of important normal tissues, but sometimes it cannot.”

Age plays a role, too. In children, radiation has a greater impact on the growing organs, making it vital to spare as much dose as possible to healthy tissue, because the developing organs of children have a much lower threshold of a “safe” radiation dose.

In addition, because of the anticipated long life ahead of children and young adults, the risk of radiation-induced second malignancies is greater and avoiding unnecessary irradiation is of paramount concern. This is why proton therapy is often the most appropriate choice to treat childhood cancers. 

Finally, exposure to prior radiation is also an important consideration. Radiation oncologists must consider how much radiation the tissue surrounding the tumor has already received in the person’s lifetime. Proton therapy can often be beneficial because it can minimize radiation to previously irradiated areas.  

With these general guidelines Fred Hutch radiation oncologists also carefully review each case, often with a group of other doctors called a tumor board — to decide if proton therapy is the best path forward. Many times, protons are used in conjunction with other cancer treatments such as surgery and chemotherapy.  

You can learn more about protons for head and neck cancers as well as reach out for a consultation here. 

A deeper look at the role of radiation therapist

Radiation therapists, also referred to as radiotherapy technologists, or RTTs, deliver daily therapy treatments to patients.

But what does this entail? John Bono, RTT, radiation therapy supervisor, who has worked at the proton therapy facility at Fred Hutch since 2013, provided some details.

“After the physicians create the treatment plan, all that information is entered into a platform called Mosaiq,” Bono said. There, radiation therapists can pull up the individual’s plan, which includes detailed information about the treatment the patient will receive, including the treatment table, the range shifter, the location of tattoos used to help guide the beam, and of course, the patient’s barcode, which is unique to each patient and identifies their personal apertures, compensators and positioning devices.

“The plan also provides details regarding the exact angle of the beam as well as the treatment fields,” he said. “Every procedure is verified and recorded. There are many fail-safes built into the process.”

Each radiation therapist (RTT) has to obtain an associate or a bachelor’s degree in radiation therapy with the required clinical training. This includes a specific number of hours in clinic, such as at the proton therapy facility, and a number of listed competencies proving proficiency. Then, students must pass the American Registry of Technologists licensing examination, and in some states, such as Washington, obtain a license. Students from Bellevue College and the Oregon Health and Sciences University have done clinical rotations at the Fred Hutch facility, under the guidance of RTT lead, Katie Weiner.

All RTTs can work in any of the four treatment rooms at Fred Hutch and deliver radiation for any of the disease sites we treat, from ocular to childhood cancers.

“When we hire a new radiation therapist, one of the parts of the interview process is gauging how well they’ll integrate with the existing team,” said Bono. “They spend a few hours shadowing the team and we can often tell right away.”

Bono and his team focus on hiring individuals who want to be of service to others. Working within such a dedicated team often amplifies this.

Nely Ramirez is one the RTTs at Fred Hutch.

“Our team is amazingly cohesive,” she said. “We are all here for the same reason: hope for our patients. We all come in knowing that there will be rough days, but it’s those days that have made us a tough, cancer-fighting family.”

Weiner, who has worked at Fred Hutch since 2014, agrees: “I think one of the fun parts of working in radiation therapy is that we constantly work within a team. There are always team members around to talk with and bounce ideas off of. In essence, we learn together, work together and grow together and that naturally creates cohesion.”

“Everyone is so supportive,” added Katelyn Gerczak, another RTT. “I’ve been able to form many friendships and grow with them, both professionally and personally.”

The work is not without challenges, of course. For Ramirez, that’s the feeling of helplessness when a patient is struggling and she can’t alleviate their anxiety.

“Patients are in a vulnerable state, and it can be challenging to help them navigate such a scary and unsure time. Each patient handles their individual situation in their own manner — it is our job to not only provide each one of them with healing therapy, but support as well,” said Weiner.

There are also tactical challenges. One of Bono’s trickiest responsibilities as a supervisor is patient scheduling.

“We’d like to be able to give every patient what they want, but there are so many criteria to consider,” he said. “For example, our morning appointments are reserved mostly for pediatric patients who require anesthesia because they can’t eat prior to their treatment. Some patients have treatment twice a day, and they require at least six hours between sessions. Sometimes we have to move patients between rooms, as well. And of course, we try to work around patients’ other medical appointments, such as chemotherapy.”

Outside of scheduling complexities, there are many parts Bono loves about his job, especially treatment planning and improving care and efficiency of his RTT team. Spending time with the patients is what draws many of the team members to radiation therapy.

“If I had to pick the most fulfilling part of my job, it would be the patients,” said Ramirez. “Every patient I meet adds immense value to my life outlook. There are days where I find myself feeling down and I see a patient smiling and it makes me realize that I should be smiling, too.”

“I love that we get to see most of our patients every day, it allows us to get to know them really well,” said Weiner. “The connections that I get to build with them are one of the most meaningful parts of my job and something that I will always cherish.”

Gerczak agrees about patients and their effect on staff at the proton therapy facility. “They truly make the proton therapy facility a wonderful place to work. They also build special bonds with each other. We have had numerous patients who’ve come back to support another patient on their graduation day. It is really rewarding to see.”

Meet clinical nurse Angelle Schilling

Clinical nurse Angelle Schilling, RN, recently joined the team at Fred Hutch from a career specializing in gastrointestinal procedures, such as colonoscopies.

Schilling, who said she likes a new challenge, decided to shift specialties to oncology. 

“It is quite different than my former role, but I am enjoying it,” she said. “New experiences and challenges are important for self-growth.”

In her new role, Schilling works with proton therapy patients across all diseases, not just gastrointestinal cancer patients.

“I have learned so much since starting here,” Schilling said. “I love to learn. It not only helps me grow as a nurse, it also allows me to educate our patients, to help them understand more about protons and radiation therapy.”

Originally from Gretna, a town outside of New Orleans, Louisiana, Schilling first studied speech and language pathology at Southeastern Louisiana University before pursuing a nursing degree at Our Lady of the Lake University in Baton Rouge.

She plans to further her nursing education and was accepted into the master's degree in nursing program at Loyola University New Orleans.

In her free time, she studies French, crochets, bakes and plays video games with her six-year-old son. Weather permitting, they can also be found riding an e-trike around the city together.

Please say “hi” to Schilling when you see her!

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