Proton therapy treatment centers are opening the door to a new era in radiation treatment for cancer patients. Proton therapy targets a controlled beam of protons at malignant tumors to kill and to halt the reproduction of cancer cells. This technology differs from X-ray radiation in that it causes less harm to healthy tissues and organs and more harm to malignant growths. The ability of this technology to precisely target tumors makes it an attractive option for treating cancers growing near vital organs. The noninvasive, painless procedure is also favored for use with children because it reduces their need for radiation and thus reduces the potential harm to their young, growing bodies.

The approval of proton therapy by Medicare and independent insurance carriers has helped make it a viable treatment modality. These sources support the needed revenue stream to amortize the cost of the complex and expensive buildings and equipment the therapy requires. The treatment alternative has been implemented in five hospitals in the United States. The experiences and influence of these trendsetters have led to more communities to consider investing in proton therapy solutions. To date, more than 50,000 people have been treated with proton therapy in the United States.

The first private proton facility

In April, ground was broken on the nation’s first private-practice proton therapy center, now being built in Oklahoma City, Oklahoma. The Oklahoma ProCure Treatment Center is being developed and funded by ProCure Treatment Centers, Inc., and their physician partners. The pioneering facility may lead to the strategic placement of similar treatment centers in metropolitan areas nationwide.

“With this facility, we can provide the most advanced external radiation treatment to the people of Oklahoma and help position Oklahoma City as a national leader in proton cancer treatment,” said Dr. W.C. Goad, ProCure Oklahoma physician partner. “With significantly less damage to healthy tissue and vastly diminished posttreatment side effects, proton therapy has superior results to conventional radiation.”

One value of the privately owned treatment center model is that the center can become a resource to all area hospitals and not just the funding party. This makes the concept more attractive as a community service and could help physicians invest in partnerships that would bring these facilities to more communities throughout the country.

A difficult build

Rarely is a design and construction team challenged with creating a facility that houses equipment to separate protons and neutrons and send the protons through circuitous paths at 70% the speed of light to radiate a cancer tumor with pinpoint accuracy. Constructing a proton therapy center requires the participation of a team that appreciates the complexities and complications of this type of building. Linbeck, a national builder headquartered in Houston, constructed the University of Texas’ M.D. Anderson Proton Therapy Center in 2005 (figure 1). Linbeck’s experience led to ProCure’s decision to bring the firm on board for their Oklahoma project. Linbeck is now the only building company in America to construct more than one proton therapy facility. Linbeck’s role began with project definition and conceptual budget development and will continue through postoccupancy analysis.

Construction of the 55,000-square-foot building is far from straightforward. While the waiting rooms, lobby, exam, and testing rooms are relatively typical in design, the treatment areas are incredibly complex (figures 2-4). The building has four treatment rooms, one with a full rotating gantry and three to accommodate fixed-beam technology. All will be equipped with robotics. The equipment bed for the gantry must be installed below grade. The 220-ton magnets in the cyclotron and the revolving gantry will be placed on grade, in rooms with concrete shielding for walls and ceilings as much as 10 to 12 feet thick. The building will provide electrical redundancy through an emergency generator and uninterrupted power supply (UPS) units.

Lessons from experience

“Having past experience in building a proton therapy facility has really helped reduce the learning curve, as we are able to communicate the challenges to the subconsultants and confirm very sophisticated concepts,” says Craig Fredrickson, LEED AP, a vice-president with Linbeck and client executive for the ProCure center. He points to lessons learned from the firm’s construction management services for the M.D. Anderson Proton Therapy Center.

For example, lining the fixed-beam treatment rooms with carbon steel plates reduces the required thickness of the concrete, which makes the square footage of the rooms larger. This is of great value, considering the size and shape of the equipment that must be housed in the rooms. However, since the equipment is literally being built from scratch to accommodate technology improvements, a physicist’s review and analysis will provide collaborative detail that will ultimately yield a plan for state-of-the-art shielding.

Linbeck’s Houston-based team knew from the beginning that they would need to hire and train subconsultants who were local to the Oklahoma City region. It would have been impractical to engage the firms that had worked on the M.D. Anderson facility; the distance from Houston to Oklahoma City is about 450 miles. So, how do you train a distant workforce for a highly complex and intricate venue such as a proton therapy center?

During the conceptual planning process, Linbeck investigated and scrutinized the Oklahoma City subcontractor market. They met with the Associated General Contractors in the city and communicated their needs and expectations. They analyzed the potential subconsultant teams and then began thorough checks to verify pricing, systems, qualifications, manpower, and experience. They also performed on-site office reviews.

Once the local players were identified, Linbeck initiated a detailed and proprietary collaborative process called TeamBuild. “This is a system we have implemented on hundreds of projects, with documented savings in excess of 20% in the majority of cases,” says Fredrickson. The collaborative model brings all key team members into the decision-making process at the conceptual phase. This includes client representatives, facility users, owners, developers, equipment suppliers, architects, engineers, constructors, subconsultants, and any other people whose input can add value to the decision making processes. TeamBuild outlines the needs and then provides directives to support the team’s efforts to develop a united game plan. “The process embraces and rewards innovation, creativity and lean construction principles,” says Fredrickson. “The up front evaluation validates plans and tests assumptions about cost and budget and building performance to adjust them for maximum benefit.”

Next, the team was introduced to a behavior-based safety program (BBS) designed by Linbeck and recognized for its effectiveness through industry scrutiny by OSHA and others and through subsequent awards. The program influences work-site behaviors and promotes safe actions through training, observations, and feedback. It is primarily observation-based and gives quantifiable measures to the participants to help each person individually assess whether a behavior they’re observing is risky.

For example, in the category related to ladders and scaffolds, the BBS checklist describes how to determine if the feet of a scaffold are on a level surface and at the correct ratio of ladder-to-task height. Checklists relative to electrical safety explain how to know if a power tool is potentially compromised. The BBS program provides a database of definitions and descriptions to give observers objective criteria from which to judge the safety of virtually any situation.

According to Fredrickson, Linbeck also provides the construction team with their Linbeck Sponsored Insurance Program (LSIP), which differs from traditional insurance in several ways. Most notably, the program covers the contractor and all eligible subcontractors and suppliers that perform work at the project site under a single insurance program. The premiums and coverage are locked in for the term of the project and do not escalate annually. Further, the coverage and the limits provided by the LSIP are much broader than most subcontractors and suppliers can carry through their individual policies. Fredrickson says the LSIP results in better and more uniform protection for the owner, contractor, and subcontractors.

The greatest challenge

Creating a building to house such complex equipment is the construction team’s greatest challenge. They must use the equipment manufacturer’s interface building document (IBD) to clarify how the very intricate proton therapy equipment interfaces with the building elements. The IBD must remain a flexible document, requiring update and revision throughout construction because of continuous improvements to equipment technology. For example, the components of a piece of equipment that may have been 10 square feet a year ago may have recently been re-engineered to only six square feet. The importance of accommodating such changes and understanding and communicating their relationship to the design is a key element to success.

In addition, early, flexible, and ongoing planning are crucial components of the process. “When you have electrical conduit and mechanical ducts and materials and systems passing through 10-foot-thick walls, there is virtually no margin for error,” says Fredrickson. “Once you pour the concrete, you can’t go back and add anything to pass through those walls. Your plan and execution of your plan have to be right.”

The end is the beginning

Once the construction is complete in November 2008, it will take about another year for installation and testing of the complex and precision-driven equipment. The center is scheduled to open in the summer of 2009 and will provide services to approximately 1,500 cancer patients each year.

ProCure’s chief executive officer, Hadley Ford, commended state, medical, and business community leaders for working together to rapidly bring proton therapy to Oklahoma. “There are no radiation cancer treatments available in the world today as precise and effective as proton therapy,” Ford said. He believes this center “provides a blueprint for the rest of the nation to follow in making proton therapy available to everyone who would benefit from the treatment.” HD