In Pavia, a ‘CERN’ that uses particle beams to treat cancer

“Patient number one? I remember him very well. He was 25 years old and had a chondrosarcoma in a critical location, near the eye and the brainstem; having just undergone an initial operation, he could not undergo further surgery. We treated him here. He’s now in excellent health, has two daughters, still writes to me and we meet up from time to time.” It was 2011 when Dr Maria Rosaria Fiore, a radiotherapist, welcomed the first patient eligible for treatment at the CNAO, the National Centre for Oncological Hadrontherapy. Today, 600 patients arrive each year, from all over Italy and even from abroad. Many are children or young adults. They come to one of only eight centres worldwide capable of using particle beams – both protons and carbon ions – to treat tumours in hard-to-reach areas or those resistant to radiotherapy.

We are in Pavia. Right next to San Matteo Hospital, yet still off the radar of those who talk about ‘health’ and think only of hospitals in the big cities. And yet it is a centre of absolute excellence within the public health system, particularly in Lombardy. And it owes this precisely to hadron therapy.

“It is a technique that, instead of using photons – that is, X-rays – utilises beams of protons and carbon ions,” explains Fiore, who has been at the CNAO since its inception and now heads the Oncological Radiotherapy Unit: “These are particles that are able to deliver the maximum dose precisely to the desired target, whilst releasing very little radiation along their path in and out.” The result: the tumour is targeted with the utmost precision, without affecting the surrounding healthy tissue. “Furthermore, carbon ions cause multiple and complex damage to the DNA of the tumour cell, preventing it from self-repairing.” In short, this means treating both inoperable tumours – because they are too close to vital organs – and those that are resistant to conventional radiotherapy. Not all of them, of course. But many. “Many belong to the large family of bone and soft-tissue sarcomas. But there are also those affecting the salivary glands, the brain, the skull base… These are rather rare tumours that we oncologists call ‘orphan’ tumours, because there are few specialist centres and few available treatments.”

The credit goes to the synchrotron, the accelerator capable of breaking down atoms and producing beams of protons and carbon ions. It is a high-tech ring 25 metres in diameter and 80 metres in circumference, housed in an underground bunker measuring 1,600 square metres and shielded by walls six metres thick. It is a miniature replica of the one used at CERN in Geneva to study matter: the same principle, the same type of machinery. But here it is used to generate particles travelling at up to 213,000 kilometres per second, to bombard diseased cells with sub-millimetre precision.

The idea originated in 2001, thanks to the insights of physicists Ugo Amaldi and Giampiero Tosi, the impetus provided by the Tera Foundation, and input from the Ministry of Health and the Lombardy Region. It involved organisations such as CERN, the National Institute of Nuclear Physics, the GSI in Darmstadt and the LPSC in Grenoble; it drew on the ideas and work of 600 companies (mostly Italian); and it secured the healthcare partnership of the six founding members (including Tera, the National Cancer Institute of Milan, Milan’s Policlinico, the IEO, the BESTA and San Matteo Hospital in Pavia). It opened at the end of 2010, gradually bringing together other pieces of a jigsaw that includes three universities (Pavia, Milan and the Politecnico), Pavia City Council and the Cariplo Foundation. This is enough to dispel many clichés about the public sector running on empty and the impossibility of creating a cohesive system. Here, it is happening. And it works: in fifteen years, it has treated 6,300 patients, almost all through the National Health Service.

“For someone in my line of work, it’s the best there is,” says Fiore: “It involves a multidisciplinary approach bringing together surgeons, oncologists and radiotherapists from all the leading centres. But there is also an internal multidisciplinary approach, because to carry out such cutting-edge treatment, you need to bring together medical physicists, bioengineers, radiotherapy technicians, specialist engineers… The patient arrives at a well-established organisation that takes full responsibility for their care. Here they find treatment, but even before that, hope.”

There you have it: hope. It’s a word that was heard frequently on 20 June too, when, somewhat unexpectedly, Pope Leo XIV stopped off at the CNAO during his visit to Pavia dedicated to St Augustine. He called it ‘a place where miracles happen’. For Fiore and his colleagues, it was ‘a flood of emotion. It amplified the meaning of our work. We talk about technology and research, but ultimately it’s all about caring for people. They are not ‘a disease’ or ‘a clinical case’, but men, women and children with a story, and people who love them. The Pope reminded us of the ultimate purpose of all this science.”

Science is poised to make further advances here. At the CNAO, work is being finalised on a new building, another bunker, new research laboratories, a second proton accelerator and one for Boron Neutron Capture Therapy, which uses neutron beams to target particularly aggressive tumours and metastases.

“The prospects are excellent,” says Fiore: “Having such a powerful tool at our disposal, we want to make the most of it.” Work is currently underway on bespoke protocols aimed at integrating hadron therapy with systemic therapies. “In a few weeks’ time, we will be inaugurating the new proton accelerator, equipped with a ‘gantry’ (a rotating head that allows the tumour mass to be targeted from multiple directions, ed.), and, later on, we will also be able to carry out treatments whilst the patient is seated”. This means adding many cancers of the chest and abdomen to the list of treatable conditions.

Above all, it means sharing more stories like the one the doctor describes as “one of the most wonderful experiences I’ve had in recent years”. He was a 42-year-old Croatian patient. “He had a chordoma with a huge tumour: it started at the sacrum and had spread into part of the pelvis. He couldn’t have surgery, but he couldn’t even lie on a stretcher because of the pain.” On that occasion, she says, she thought they wouldn’t make it. “But we actually managed to complete the treatment. At his second check-up, six months later, he walked into the clinic on just one crutch. He was walking. That’s exactly why a place like this exists.”