The symmetric configuration of EBT3 presents a major improvement for film handling. EBT3 has similar dosimetric performance as its precursor EBT2 and can, thus, be applied to dose verification in IMRT in the same way. For dose verification in proton therapy the underresponse in the Bragg peak region has to be taken into account.

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Radiochromic films such as Gafchromic EBT2 or EBT3 films are widely used for dose determination in radiation therapy because they offer a superior spatial resolution compared to any other digital dosimetric 2D detector array. The possibility to detect steep dose gradients is not only attractive for intensity-modulated radiation therapy with photons but also for intensity-modulated proton therapy. Their characteristic dose rate-independent response makes radiochromic films also attractive for dose determination in cell irradiation experiments using laser-driven ion accelerators, which are currently being investigated as future medical ion accelerators. However, when using these films in ion beams, the energy-dependent dose response in the vicinity of the Bragg peak has to be considered. In this work, the response of these films for low-energy protons is investigated. To allow for reproducible and background-free irradiation conditions, the films were exposed to mono-energetic protons from an electrostatic accelerator, in the 4-20 MeV energy range. For comparison, irradiation with clinical photons was also performed. It turned out that in general, EBT2 and EBT3 films show a comparable performance. For example, dose-response curves for photons and protons with energies as low as 11 MeV show almost no differences. However, corrections are required for proton energies below 11 MeV. Care has to be taken when correction factors are related to an average LET from depth-dose measurements, because only the dose-averaged LET yields similar results as obtained in mono-energetic measurements.

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This study showed a pronounced increase of secondary neutron H*(10) values inside the proton treatment room with increasing proton energy without beam modifiers. For example, in beam direction this increase was about a factor of 50 when protons of 75 MeV and 200 MeV were compared. The existence of a peak of secondary neutrons in the MeV region was demonstrated in beam direction (0°). This peak is due to evaporation neutrons produced in the existing surrounding materials such as those used for the gantry. Therefore, any simulation of the secondary neutrons within a proton treatment room must take these materials into account. In addition, the results obtained here show that the use of a range-shifter increases the production of secondary neutrons inside the treatment room. Using a range-shifter, the higher neutron doses observed mainly result from the higher incident proton energy (118 MeV instead of 75 MeV when no range-shifter was used), due to higher neutron production cross-sections.

Proton beam RT has significant potential to improve treatment related side effects in the bowel compared to photon beam RT in patients with advanced cervix carcinoma.