Comparison of proton and photon dose distributions

Recently, there has been considerable work, as yet largely theoretical, in developing ways to improve the dose distributions which can be achieved with x-rays. Foremost among these developments are the use of non-coplanar beam directions, the use of intensity-modulated beams, and the implementation of computer-controlled delivery of complex plans using new beam modifiers such as multi-leaf collimators and beam scanners. One way of improving the dose distributions which have been achieved with conventional radiations is to use protons, with their quite different physical characteristics but very similar radiobiological properties as compared with supervoltage x-rays. Some substantial experience has been gained in the use of protons which has confirmed clinically that better results have been obtained as a result of their better dose distributions. Indeed, it is fair to say that the advantages which protons have demonstrated are, in large part, responsible for the renewed interest in improving the dose distributions from all radiation modalities. So much better are the dose distributions which the new techniques, mentioned above, offer that there is the impression that, with their use, photons can deliver dose distributions as good as can be obtained with protons. In this paper, the extent of the possible improvement will be discussed. It will be suggested that the integral dose is relatively little affected by the treatment technique - so that the lower normal tissue doses which the new approaches offer is almost always at the price of delivering dose to a larger volume. Protons can be matched pencil beam for pencil beam with photons - and then almost always deliver substantially less dose outside the target volume. Ultimately, the clinical importance of the differences will have to decided by clinical trial