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However, when considering linear energy transfer (LET) and RBE effects, alternative beam arrangements should be investigated.<\/jats:p><\/jats:sec><jats:sec><jats:title>Purpose<\/jats:title><jats:p>To investigate the dose and dose averaged LET (LET<jats:sub>d<\/jats:sub>) impact of using new beam arrangements rotating beams 5\u00b0\u201315\u00b0 posteriorly to the laterals in prostate cancer treated with pencil\u2010beam\u2010scanning (PBS) proton therapy.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Twenty patients with localized prostate cancer were included in this study. Four proton treatment plans for each patient were generated utilizing 0\u00b0, 5\u00b0, 10\u00b0, and 15\u00b0 posterior oblique beam pairs relative to parallel\u2010opposed lateral beams. Dose\u2010volume histograms (DVHs) from posterior oblique beams were analyzed. Dose\u2010LET<jats:sub>d<\/jats:sub>\u2010volume histogram (DLVH) was employed to study the difference in dose and LET<jats:sub>d<\/jats:sub> with each beam arrangement. DLVH indices, , defined as the cumulative absolute volume that has a dose of at least <jats:italic>d<\/jats:italic> (Gy[RBE]) and a LET<jats:sub>d<\/jats:sub> of at least <jats:italic>l<\/jats:italic> (keV\/\u00b5m), were calculated for both the rectum and bladder to the whole group of patients and two\u2010sub groups with and without hydrogel spacer. These metrics were tested using Wilcoxon signed\u2010rank test.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Rotating beam angles from laterals to slightly posterior by 5\u00b0\u201315\u00b0 reduced high LET<jats:sub>d<\/jats:sub> volumes while it increased the dose volume in the rectum and increased LET<jats:sub>d<\/jats:sub> in bladders. Beam angles rotated five degrees posteriorly from laterals (i.e., gantry in 95\u00b0 and 265\u00b0) are proposed since they achieved the optimal balance of better LET<jats:sub>d<\/jats:sub> sparing and minimal dose increase in the rectum. A reduction of V(50 Gy[RBE], 2.6 keV\/\u00b5m) from 7.41 to 3.96 cc (<jats:italic>p<\/jats:italic> &lt; 0.01), and a slight increase of V(50 Gy[RBE], 0 keV\/\u00b5m) from 20.1 to 21.6 cc (<jats:italic>p<\/jats:italic> &lt; 0.01) were observed for the group without hydrogel spacer. The LET<jats:sub>d<\/jats:sub> sparing was less effective for the group with hydrogel spacer, which achieved the reduction of V(50 Gy[RBE], 2.6 keV\/\u00b5m) from 4.28 to 2.10 cc (<jats:italic>p<\/jats:italic> &lt; 0.01).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Posterior oblique angle plans improved LET<jats:sub>d<\/jats:sub> sparing of the rectum while sacrificing LET<jats:sub>d<\/jats:sub> sparing in the bladder in the treatment of prostate cancer with PBS. Beam angle modification from laterals to slightly posterior may be a strategy to redistribute LET<jats:sub>d<\/jats:sub> and perhaps reduce rectal toxicity risks in prostate cancer patients treated with PBS. However, the effect is reduced for patients with hydrogel spacer.<\/jats:p><\/jats:sec>","DOI":"10.1002\/mp.16008","type":"journal-article","created":{"date-parts":[[2022,10,8]],"date-time":"2022-10-08T12:53:16Z","timestamp":1665233596000},"page":"7428-7437","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Technical note: Investigation of dose and LET<sub>d<\/sub> effect to rectum and bladder by using non\u2010straight laterals in prostate cancer receiving proton therapy"],"prefix":"10.1002","volume":"49","author":[{"given":"Yunze","family":"Yang","sequence":"first","affiliation":[{"name":"Department of Radiation Oncology Mayo Clinic Arizona  Phoenix Arizona USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jean\u2010Claude M.","family":"Rwigema","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology Mayo Clinic Arizona  Phoenix Arizona 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