Sir,

Radiotherapy of pediatric cancer patients can become quite challenging due to immobility of patients during the treatment procedure. Basu et al., [1] published an article in Clinical Cancer Investigation Journal highlighting anesthesia versus sedation during the course of radiotherapy of pediatric cancer patients. Some of the cancer centers may not choose to anesthetize or sedate pediatric cancer patients. This can be due to increase in treatment time, thus ultimately leading to the decrease of the throughput of patients at Busy Cancer Center. Some of the commonly used radiotherapy techniques in photon therapy are three-dimensional conformal therapy (3DCRT), intensity modulated radiation therapy (IMRT), volumetric modulated arch therapy (VMAT). [1],[2] The shorter treatment time can be very important in order to reduce the setup uncertainties, inter- and intra-fractional errors, etc. It has been mentioned that treatment time using VMAT is shorter than using IMRT. However, the dose distributions generated by both the IMRT and VMAT were found to be comparable for various disease sites. [3],[4]

It is well known that radiation therapy often delivers dose to the normal tissues while delivering dose to the cancer tumor volume. This could lead to secondary cancer in pediatric patients. Hence, it is essential to come up with an efficient radiotherapy technique which can deliver maximum dose to the target volume while minimizing dose to the critical structures so that secondary cancer can be avoided and normal tissue toxicities can be reduced. Radiation therapy techniques (3DCRT, IMRT, and VMAT) mentioned in the first paragraph fall in the category of photon therapy. Recently, medical communities have shown a great interest to utilize proton therapy to treat the cancer. [5],[6] In proton therapy, most of the dose is deposited in the tumor volume with sharp lateral penumbra and very steep dose-fall off at the end of proton beam path. [5] Researchers from Harvard Medical School [6] found that the risk of radiation-induced secondary cancer in pediatric patients using proton therapy technique is very less than using photon therapy. Dose-volume results of proton therapy plans were also found to be better than that of photon therapy plans for the pediatric patients. [7] In conclusion, literature suggests that radiotherapy using proton therapy sounds promising and it can improve the survival rate of pediatric patients and as well as reduce the chance of getting secondary cancer in the future.