Optimal combined proton–photon therapy schemes based on the standard BED model

This paper investigates the potential of combined proton–photon therapy schemes in radiation oncology, with a special emphasis on fractionation. Several combined modality models, with and without fractionation, are discussed, and conditions under which combined modality treatments are of added value are demonstrated analytically and numerically. The combined modality optimal fractionation problem with multiple normal tissues is formulated based on the biologically effective dose (BED) model and tested on real patient data. Results indicate that for several patients a combined modality treatment gives better results in terms of biological dose (up to improvement) than single modality proton treatments. For several other patients, a combined modality treatment is found that offers an alternative to the optimal single modality proton treatment, being only marginally worse but using significantly fewer proton fractions, putting less pressure on the limited availability of proton slots. Overall, these results indicate that combined modality treatments can be a viable option, which is expected to become more important as proton therapy centers are spreading but the proton therapy price tag remains high. (paper)