Between Surgery and Cirrhosis
David Mitchell, a 64-year-old retired structural engineer from Vancouver, had been monitored for hepatitis B-related cirrhosis for over a decade. In mid-2025, routine surveillance ultrasound revealed a 3.8 cm lesion in segment VI of his liver. Subsequent triple-phase CT and MRI confirmed: hepatocellular carcinoma, stage II (T2N0M0, BCLC stage A).
His liver function, however, complicated everything. Child-Pugh score was class B (7 points): albumin 3.1 g/dL, bilirubin 2.1 mg/dL, INR 1.4, and mild ascites controlled with diuretics. The tumor was operable — but his liver might not tolerate the resection. Vancouver General's hepatobiliary tumor board estimated a 30% risk of post-hepatectomy liver failure. They offered transarterial chemoembolization as a bridge, but candidly acknowledged it was not curative for a lesion of this size.
The alternative — proton therapy — was unavailable in Canada. The nearest proton center was in Seattle, where a full course would cost over $200,000 USD, entirely out of pocket.
Shanghai's Proton Experience
David's adult daughter found SSAnkang while researching proton therapy abroad. Within a week, our oncology coordinator had convened a virtual tumor board with the Shanghai Proton and Heavy Ion Center — one of only five active proton centers in mainland China, treating hepatocellular carcinoma since 2014 with published five-year local control rates exceeding 90%.
The Shanghai team proposed an 8-fraction hypofractionated proton regimen over two weeks, using pencil-beam scanning with respiratory gating to track the tumor's motion during breathing. Total biologic effective dose was calculated to be equivalent to a far longer conventional photon course — but with exit dose to the uninvolved liver and right kidney reduced to near zero. A liver-specific MRI with hepatobiliary contrast was ordered for precise treatment planning.
Two Weeks That Changed the Trajectory
David and his wife flew to Shanghai and settled into a serviced apartment 10 minutes from the proton center. Treatment planning took five days: CT simulation, MRI fusion, custom immobilization, and plan QA with independent dose verification. Each daily fraction took approximately 25 minutes on the treatment table.
Side effects were minimal. By fraction 4, David reported mild fatigue (grade 1) — "like I'd stayed up too late the night before." No nausea, no skin reaction, no decline in liver function tests. He and his wife spent afternoons exploring Shanghai's French Concession. "It felt less like cancer treatment and more like an unusual vacation," he later said.
The Six-Week Scan
MRI at six weeks post-treatment showed the lesion had shrunk from 3.8 cm to 1.2 cm with no arterial enhancement — consistent with a complete radiologic response by modified RECIST criteria. His liver function, remarkably, had not declined. Albumin had actually improved to 3.4 g/dL, likely because the underlying cirrhosis management continued uninterrupted by any surgical insult.
Total cost for the full proton course, treatment planning, all imaging, and three weeks of accommodation in Shanghai: $52,000 USD. Roughly one-quarter of the US proton price. At 12-month follow-up, David remained in complete remission with preserved liver function. "They didn't just treat the tumor," he wrote to us, "they respected the liver I have left."