The Potential of Proton Therapy for Locally Advanced Breast Cancer: Clinical and Technical Considerations

Round 1

Reviewer 1 Report

In the following review, the authors highlight both clinical and technical considerations for the administration of proton radiotherapy in patients with locally advanced breast cancer.

 

The main potential benefit of proton therapy comes from the ability to spare radiation dose to critical organs due to large dose declines.

 

1. Both the goals and conclusions of this review are broad and radical

2. The images are of good quality and standardized

 

To conclude, this is a potentially good review.

Author Response

In the following review, the authors highlight both clinical and technical considerations for the administration of proton radiotherapy in patients with locally advanced breast cancer. The main potential benefit of proton therapy comes from the ability to spare radiation dose to critical organs due to large dose declines.

1. Both the goals and conclusions of this review are broad and radical

We have softened the wording as follows:

“Throughout this review, we highlight a subset of literature to help guide clinician decision making and facilitate evidence-based discussions regarding the provision of proton therapy in the setting of locally advanced breast cancer. Patients with locally advanced breast cancers comprise a growing number of patients globally. This unique subset of our patient population entails an increased complexity of planning due to the need for comprehensive nodal coverage and the higher likelihood of breast reconstruction. The favorable prognosis of this group might benefit from vigilant consideration of modalities that may mitigate treatment related toxicity, including cardiopulmonary sequelae. The burgeoning field of proton radiotherapy in this setting holds promise for improving target coverage and decreasing dose to the organs at risk. The evidence surrounding appropriate target volumes and planning approaches, taking into account the unique physical properties of protons, continues to evolve. Further study is needed to appropriately harness this promising technology in service to our patients.”

 

2. The images are of good quality and standardized To conclude, this is a potentially good review.

Thank you.

Reviewer 2 Report

Well-written manuscript.

Very well summarized points and messages proving the appropriate target volumes and planning approaches for promising technology to serve our patients.

Appropriately check for spelling and grammar checks.

 

Author Response

Well-written manuscript. Very well summarized points and messages proving the appropriate target volumes and planning approaches for promising technology to serve our patients. Appropriately check for spelling and grammar checks.

Thank you. We have checked for minor spelling and grammar.

Reviewer 3 Report

The review papers provide information about the potential of Proton therapy in the treatment of breast cancer. This work has meaningful in the field. However, the information and references were limited.  My comments are as followed:

1.       The theory of proton therapy needs to be given in the paper.

2.       For the convenience of the reader, the data number should be presented by graph or table.

3.       Figure 3 presents the differences in the effect of photo radiotherapy and proton radiotherapy on cardiac and pulmonary structures. How about breast cancer?

4.       The presence of figures is repeated. The resolution of figures also needs to be enhanced. 

Author Response

The review papers provide information about the potential of Proton therapy in the treatment of breast cancer. This work has meaningful in the field. However, the information and references were limited.  My comments are as followed:

1. The theory of proton therapy needs to be given in the paper.

Thank you for your comment. We have expanded on the theory of proton therapy in the introduction as follows:

“Proton therapy holds promise in addressing this limitation, due its unique physical properties. The characteristic behavior of a proton entails the deposition of the treatment dose at a known depth with a subsequent, rapid dose-fall off. This property, termed the “Bragg peak”, has been utilized to treat a variety of precariously located tumours while sparing low doses to normal surrounding tissue (Figure 1)^2,3. The enthusiasm surrounding proton therapy stems from this ability to elicit abrupt dose fall-off distal to the target of interest, thereby sparing low doses of radiation to nearby organs at risk.”

 

2. For the convenience of the reader, the data number should be presented by graph or table.

Thank you. We have included an additional table as follows:

Table 1: Particle therapy facilities in clinical operation as of October 2022.

 

3. Figure 3 presents the differences in the effect of photo radiotherapy and proton radiotherapy on cardiac and pulmonary structures. How about breast cancer?

Thank you. We have included an additional figure to better show the doses to the breast cancer in addition to the oars:

Figure 4. An illustration highlighting differences in the use of (A) 3D conformal photon radiotherapy versus (B) Volumetric Modulated Arc Therapy (VMAT) versus (c) Proton radiotherapy (Figure courtesy of Dr. R.B. Jimenez).

 

 

4. The presence of figures is repeated. The resolution of figures also needs to be enhanced.

Thank you. We have corrected this repetition and enhanced the resolution.

Round 2

Reviewer 3 Report

I recommend this paper for the publishing. I believe this work will make a valuable contribution to the field.