Proton beam therapy is the great new hope for cancer treatment, and the enormously complex buildings that house it are going up surprisingly fast
‘These are the most complex projects you’ll ever get involved in’. Kevin Turnbull, director of JDDK isn’t talking about major mixed use, high rise or station projects, but a series of low rise brick clad buildings. Modest they may look from the outside, but these are among a number delivering the very latest in cancer treatment: proton beam therapy (PBT).
PBT is an advanced form of radiotherapy, which uses a beam of high energy protons – small parts of atoms. Until fairly recently, UK cancer patients had to travel overseas to receive it, but now one NHS centre is already up and running – The Christie NHS Trust facility in Manchester – and in London the University College London Hospitals (UCLH) NHS Foundation Trust is developing a second. At the same time, specialist Proton Partners International delivered the first PBT treatment in the UK from its Rutherford Cancer Centre in Wales, and began rolling out a series of further centres across the UK, of which three so far have been designed by JDDK.
This advanced treatment brings fresh challenges for buildings that already call for intricate, highly efficient combinations of spaces and uses, and the provision of protective shielding for nuclear medicine. Put all this alongside the needs of patients, families, staff and stakeholders and a rapidly changing health landscape, and you see what Turnbull is getting at.
PBT technology delivers treatment with incredible precision, and the construction of the facilities housing it call for the same exactitude, as BBC television viewers saw in a programme about The Christie and UCLH facilities, The £250 million pound cancer cure, screened in July. UCLH’s centre is housed in an 11 storey building, which has the added complication of having five storeys below ground.
The client wanted the building to maximise its Euston site, which puts it close to other UCLH medical services. Building height was restricted to six storeys by a view corridor, ‘so the only way to realise the project was to push down as far as we could go’, says Sheila Carney, director of Scott Tallon Walker Architects, the project’s lead designer. The lowest two storeys house the PBT centre, with an interstitial plant room above. Level -1 houses day surgery theatres, with eight operating theatres and clinical support space. At ground level are the main public entrance and patient drop off areas, plus the main imaging department. Rising above are five floors of inpatient wards, including a 10 bed critical care unit and other support space. A central atrium separates the L-shaped building from a lower three storey courtyard building in the centre of the development.
The source of the proton beam is extracted from a cyclotron, which accelerates protons to around two thirds the speed of light. The beam is steered and focused by magnets to four treatment rooms where gantries deliver the treatment, rotating around the patient as they lie on a central table. The kit is massive and heavy: ‘The cyclotron is the weight of a jumbo jet and the size of a family car,’ says Derek D’Souza, medical physicist at UCLH NHS Foundation Trust. The gantries are three storeys high, and UCLH has one in each of its four treatment areas. And it must all be shielded for radiation protection.
Scott Tallon Walker was brought into the project team early, as the client was bidding to secure funding for the PBT centre. ‘Three equipment vendors gave us technical information to allow us to test the design to see it would fit. We accommodated four treatment rooms plus the cyclotron – but we must have looked at 50 different design options in all,’ says Carney. ‘We then had a soft dialogue with the main vendors to check the designs, and after that designed three schemes to around RIBA Stage 2.5.’ Further whittling down of the equipment supplier, as well as the contractor, continued until team and solution were decided. Since then the same personnel have been working on the project, which has aided understanding, says Carney. ‘We’ve all been through the options and have a huge amount of history.’
The practice had previously worked on cyclotron facilities for radio pharmaceutical and good manufacturing practice production and so was familiar with the provision of nuclear shielding, but it sought specialist guidance and visited PBT facilities in locations from Dallas to Delft. D’Souza’s team was on the visits too. ‘The architects learned with us,’ he recalls. ‘We got to know them well and gave them physics lessons on the plane.’
The cyclotron and treatment rooms sit in a maze-like concrete bunker some 56m long by more than 20m deep. Each treatment room is around 8m wide by 10.5m high by 4m long, with walls ranging from 2-5m in thickness. These walls have a huge amount of services running through them with extraordinary precision, says Carney. ‘The angles of ductwork couldn’t be more than 35˚. We made modular ductwork units and worked closely with the equipment vendor, because when you’re working 30m below ground you cannot go back and redo things – it had to be right.’
The project was modelled in 3D BIM, an approach promoted by the architect ahead of the 2016 government mandate. Kevin Bates, director at Scott Tallon Walker, says: ‘We were already set up to do it and were keen to push BIM as a way of designing, integrating and co-ordinating all the major equipment. It has been crucial in areas like services penetration through gantry walls, representing the clinical areas and helping clients understand the building.’ D’Souza confirms the latter: ‘Seeing how building and equipment merged in BIM was very helpful for us. It was also useful for the equipment manufacturers to see clashes.’
The equipment has been lowered into place, although the facility will not open until 2020. It will stay there for several decades, says D’Souza, with allowance made for maintenance. ‘Hardware can go through lifts or lift shafts and we have extra conduits for cables.’
When the building is complete passers by will see a layered facade, which has an outer veil combined with a sophisticated unitised cavity glazing system, itself layered to accommodate patient controlled blinds. Between the external and inner layers there is a walkway to allow access for maintenance and cleaning without disruption to those inside. Floor-to-ceiling glazing in patient bedrooms and garden terraces are among features that will help humanise and enhance the clinical environment, the architect having drawn on the experience of patients who have had PBT overseas to create a positive environment.
Learning from repetition
JDDK came to its first Rutherford Cancer Centre project, in Bedlington, Northumberland, with a track record in the hospice sector but, like most in the UK, little knowledge of PBT. ‘It has been a massive learning curve for us,’ says Turnbull. ‘Especially if you bear in mind that our first project went in for planning just eight weeks after we were appointed.’ Since then it has worked with the same client, Rutherford Estates, on projects in Reading and Liverpool, and has a fourth in the pipeline.
Its centres have a cyclotron and single treatment gantry, plus radiotherapy equipment, which sit alongside chemotherapy, diagnostics, imaging and other services. The centres’ common aesthetic comes from the client’s aspiration for design consistency and patient needs, says Turnbull. ‘We work from the patient perspective. This is probably the most stressful part of a patient’s life, so factors like natural light and stress-free wayfinding are extremely important.’
In these centres the bunker can appear dominant. ‘We basically have a 30m x 15m x 11m high concrete box. You can’t hide it, so it’s a question of how you treat it,’ says Turnbull. ‘We have a welcoming front elevation, with equipment and vaults to the rear – at all three sites you drive past the vault.’ Two removable panels in the roof allow for equipment to be installed.
The architect draws on the expertise of radiation protection advisers and specialist equipment providers in designing bunkers, as well as using BIM for its projects. ‘Equipment manufacturers produce site planning guides of technical parameters. We had a document of around 150 pages,’ says Turnbull. That learning never stops, he adds. ‘There can be small technological advances that make construction and operation more efficient and provide greater futureproofing. You might find out that a project in Madrid puts a cable six feet to the right and achieves greater efficiency, for example.’
In its projects Rutherford Estates has used a range of bunker constructions. North-umberland and Reading have sandwich panel construction, with prefabricated concrete outer and inner layers filled with a granular material. Liverpool has an in situ concrete shield with traditional rebar, and linear accelerators for radiotherapy on the Reading project are shielded using a heavy block solution.
The ongoing working relationship promoted by Rutherford Estates has allowed JDDK to enter an informal partnership with structural and civil engineer Fairhurst and electrical and mechanical consultant Desco. The architect sees numerous benefits coming from collaboration, not least the fact that it has worked under traditional contract arrangements for two projects. ‘We’ve provided comprehensive information and worked with a host of specialist suppliers, so are able to add value,’ Turnbull says. It is also carrying out research projects, evaluating nine alternative vault configurations to see how rebar can be minimised, and looking at ways of limiting energy consumption. Post-occupancy evaluation from the first projects is starting to inform current work.
Rutherford Estates continues to build expertise on UK projects, and the working relationship is allowing JDDK to offer its services outside the UK, alongside other members of the design team, cost consultant boydengroup and Rutherford Estates as project manager.
You might find out that a project in Madrid puts a cable six feet to the right and achieves greater efficiency, for example
Complex and caring
Even without PBT facilities, cancer centres can be immensely complex buildings, with design and delivery needing to respond to shifting operational and care priorities. The Clatterbridge Cancer Centre NHS Foundation Trust is delivering Liverpool’s first cancer hospital on a tight site beside the Royal Liverpool University Hospital. Originally the building was planned to have eight storeys, but the transfer of the hospital’s haemato-oncology service gave the potential for the centre to treat blood cancer on the same site as solid tumours.
In response its architect, BDP, grew the design by three storeys. The triangular floor plans are packed with a jigsaw of uses, including six radiotherapy bunkers, chemotherapy, surgery, outpatient and inpatient care with 101 ensuite inpatient rooms, plus dedicated facilities for teenagers and young adults and bone marrow transplant. ‘We probably restacked the building a dozen times to get everything in place and get daylight in,’ says Ged Couser, architect director of BDP. The latter is achieved using glazed facades and two atriums: a larger triangular space extending down to the lower ground radiotherapy waiting area, and a second smaller area extending up from level 2. The base of the building is peeled back to make space for a winter garden, while upper levels step back to give terraces, backed by social spaces.
Inside, the building is designed for future care needs. ‘We have soft spaces – meeting rooms and office space – interlaced with treatment spaces,’ explains Couser. Softer spaces can be adapted to provide additional imaging facilities and two more radiotherapy bunkers. The building also provides space for clinical trials that could shape future treatment. ‘Research and treatment professions are having to work more closely together,’ says Couser, who is also designing a dedicated research facility for The Christie NHS Foundation Trust in Manchester, to replace its fire damaged Paterson Building, which will include shared collaborative space for the two.
The cancer centre is under construction by Laing O’Rourke and due to open next year, but its curving prow is already starting to earn it the local nickname of ‘the liner’. Far from hiding cancer care from view, the design is deliberately transparent, and the glazed facade, terraces and garden give patients a connection with the natural world. The facade also has a deeper significance, explains Couser: ‘Original conversations focused on it being a crystalline expression of the cancer treatment taking place inside.’
The project is funded by the NHS and the government, with a public appeal contributing £15 million. The early choice of the unitised facade and firm cost control are helping the delivered building remain true to its concept, says Couser: ‘We’ve had a really good relationship with the cost consultant, Arcadis, to make sure things we are suggesting are affordable. We have been able to remain consistent because we’ve had that advice.’
Quite rightly Couser – like others working on such projects – is proud of the building and the environment it will give patients and staff. ‘It will have spaces that are beautiful and calming,’ he says. And in a medical environment increasingly dominated by advanced technology, that is important too.