The history of the National Centre for Oncological Hadrontherapy (CNAO) began with the publication in May 1991, of a report entitled “For a Centre of Teletherapy with hadrons” by Ugo Amaldi and Giampiero Tosi. Tosi was a well-known Italian medical physicist and the director of the Health Physics of the Niguarda Hospital (Milan, Italy). Ugo Amaldi, a particle accelerator physicist, was a former member of the ’Istituto Superiore di Sanità, and was then at CERN in Geneva where he directed the collaboration of about five hundred physicists for the creation and use of one of the four main LEP accelerator experiments.
The 1991 Report aroused the interest of Nicola Cabibbo, then President of INFN and in 1992 initial funding was provided for a study of a new accelerator that could accelerate both protons and light ions for use in the treatment of deep tumors. The study, funded by INFN, was called ATER, an abbreviation of “AdroTERapia”the word coined by Amaldi for this new type of radiation therapy.
In 1992, the TERA Foundation was created with headquarters in Novara to raise money and staff necessary for the design of the Centre. By 2010 more than 170 physicists, engineers, and technicians were either employed at or were fellows of TERA.
Between 1992 and 2002 three complete designs were made for the Centre, based on synchrotrons of different characteristics, suitable for the possible deployment first in Novara (years 1993-1995) and then in Milan, near the Abbey of Mirasole (1996 -1999). But a series of constraints prevented the realization of these projects.
In 1995, in order to promote the development of hadrontherapy throughout Europe, Amaldi convinced the Directorate of CERN to examine the opportunity for designing a European synchrotron to produce carbon ions and protons optimized for cancer therapy. This study was called the Proton Ion Medical Machine Study (PIMMS) and was completed in 2000. TERA planned a more compact version of the synchrotron called PIMMS / TERA which later evolved into the final CNAO version of the machine built in Pavia.
Umberto Veronesi, appointed Minister of Health in May 2000, decided to fund the implementation of the proposed Centre and in the spring of 2001 the CNAO Foundation was created. At the same time the newly appointed Minister of health Girolamo Sirchia, settled on a Committee to analyze the project and as soon as a positive opinion was issued in November of 2001 the Italian Council of Ministers Government appointed Erminio Borloni as the first CNAO President.
Erminio Borloni introduced a managerial approach in the creation of the Centre and, together with the founding institutions included in the Ministerial Decree, he succeeded in creating a network of national and international collaborators that are still the backbone of the CNAO. The President also recruited young, qualified and highly motivated personnel from TERA to work together with the organizations implementing the construction phase of the project. These personnel then became the main group for the next phase of the project: management of CNAO.
The founding members of CNAO are: the Ospedale Maggiore Policlinico Mangiagalli e Regina Elena (Milan), the Policlinico San Matteo (Pavia), the Istituto Nazionale dei Tumori (Milan), the Istituto Neurologico Besta (Milan), the Istituto Europeo di Oncologia (Milan) and the Fondazione TERA (Novara). The founders were joined by additional institutional partners: INFN, University of Pavia, University of Milan, Milan Polytechnic, the Municipality of Pavia and the Cariplo Foundation.
The years from 2002 to 2004 were essentially devoted to build the management team, acquire a solid foundation of financial contributions to the project and complete the design and specifications of the buildings, facilities and the high technology equipment needed. With this organizational setup deployed in the field, the actual construction of the CNAO began in the summer of 2005, following the ceremony of the laying of the foundation stone conducted on March 5th, 2005.
The years from 2005 to 2009 were focused on completing the work in the shortest time possible, while obtaining the highest ratio of quality to cost. More than 400 companies worked for CNAO, 350 of which of which were Italian. The work required the granting of more than a thousand orders and contracts; the preparation of 15 bids, and the obtainment of over 70 authorizations in areas ranging from construction to safety, radiation protection and facility operation.
The construction phase of the Centre was completed on February 15th, 2010, and the second phase began, comprising clinical trials which will lead to the treatment of about one hundred twenty patients selected from around 20 pathologies deemed to be treatable with hadrontherapy. This phase which covered the biennium 2010-2012, allowed for the scientific validation of hadrontherapy in an Italian hospital setting. It also laid the foundation for next phase of the Centre’s operation that will treat about 3000 patients per year, expanding the clinical indications and conducting clinical radiobiological and technology research activities.
"The realization phase lasted for 5 years, from 2005 to 2010 and 133M€ were invested. At the end of the construction, the Italian Health Ministry requested a three years clinical trial phase, whose total cost has been equal to 37.2 M€. This path brought to the CE label of the CNAO medical device and, in a short time, hadrontherapy treatments will be included in the list of the basic therapies of the Italian Health System.
The CNAO project has been realized thanks to an important network of national and international collaborations, that allowed for a big saving in realization costs, guaranteeing a training of outstanding expertise, as well. As a result, it is with great interest that many projects in the world look at CNAO as a model and ask for collaboration agreements and for support in the realization of similar centers”.