Proton beam radiotherapy for anal and rectal cancers

Gastrointestinal cancers are bordered by radiosensitive visceral organs, resulting in a narrow therapeutic window. The search for more efficacious and tolerable therapies raises the possibility that proton beam therapy's (PBT) physical and dosimetric differences from conventional therapy may be better suited to treat both primary and recurrent disease, which carries its own unique challenges. Currently, the maximal efficacy of radiation plans for primary and recurrent anorectal cancer is constrained by delivery techniques and modalities which must consider feasibility challenges and toxicity secondary to exposure of organs at risk (OARs). Studies using volumetric modulated arc therapy (VMAT) and intensity modulated radiation therapy (IMRT) demonstrate that more precise dose delivery to target volumes improves local control rates and reduces complications. By reducing the low-to-moderate radiation dose-bath to bone marrow, small and large bowel, and skin, PBT may offer an improved side-effect profile. The potential to reduce toxicity, increase patient compliance, minimize treatment breaks, and enable dose escalation or hypofractionation is appealing. In cases where prognosis is favorable, PBT may mitigate long-term morbidity such as secondary malignancies, femoral fractures, and small bowel obstruction.