Cancer treatment debate asks: is proton beam proliferation outpacing evidence?

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In any talk I give to journalists, I encourage them to look into the proliferation of proton beam facilities for cancer therapy. Few have done so with any zeal.

• The New York Times did a good job.

• The Columbus Dispatch did not.

Journalist Merrill Goozner gives ample food for thought in an article in the Journal of the National Cancer Institute, “The Proton Beam Debate: Are Facilities Outstripping the Evidence?” (subscription required for full access). Excerpt:

“A recent report from the Agency for Healthcare Research and Quality (AHRQ) found no evidence to support claims that cancer patients undergoing pricey proton beam radiation therapy (PRT) achieve better outcomes or experience fewer side effects than patients receiving traditional photon radiation.

In the report’s wake, proton therapy practitioners are pushing for the first trial comparing the two approaches for prostate cancer, which is the fastest growing use of PRT. The hope for PRT is that it will cause less collateral damage to surrounding nerves and tissue than intensity-modulated radiation therapy (IMRT), the most advanced form of traditional photon radiation.

“It hasn’t proven itself to be superior,” said Anthony L. Zietman, M.D., professor of radiation oncology at Harvard Medical School in Boston, whose affiliated Massachusetts General Hospital runs one of seven operating proton beam cancer treatment centers in the U.S. “We’ve applied for a comparative-effectiveness grant to do a head-to-head trial with IMRT with the same radiation dose,” he said. The primary endpoint is quality of life.

Even if funded, it will be years before the results of such a trial are known. With dozens of facilities already built or in development worldwide, use of the technology and the controversy surrounding it are bound to grow. In the U.S., where at least three new $100 million-plus proton beam facilities are either under construction or in the planning stage, the costly treatment could dramatically increase Medicare spending on prostate cancer care alone.”

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Greg Pawelski

April 5, 2010 at 11:01 am

I am not a proponent of “diffuse” radiation therapy. So the high energy proton beam, which is a “focused” radiation technique, is appealing to me, although at a more expensive approach. Accuracy is the key to effective radiation treatment with minimal collateral damage.
However, this posting is about the proliferation of proton beam outpacing evidence. Proton therapy still requires manual beam attenuation and there is no integrated feedback. I understand that better technology is being developed to eliminate the need for manual beam attenuation and promoting 3D control, but it’s five years or so away.
Even so, today there are still fewer than 20 systems worldwide. Several factors have inhibited the proliferation of proton beam therapy. It is not indicated in every disease because malignancies are not always in close proximity to functionally sensitive anatomy.
Brian Klepper interviewed Brian Baker for Community Oncology. Baker is an executive of Regents Health Resources, which helps hospitals and physicians develop and manage their medical imaging services. He said that “if you look at cancer trends worldwide and then estimate proton beam therapy use based on today’s indications, the world market opportunity is only around a total of 250 units. That need will likely change as proton beam adopts some of the automation technologies.”
Baker says that “a four-gantry proton therapy center costs as much as a small hospital ($125 million). The cost of proton beam equipment alone is well over $50 million.” Proton beam is reimbursed at $25,000 (on average) per patient. And Medicare increased reimbursement. It’s also worth noting that the physics behind a 900-ton synchrocyclotron getting those protons close to the speed of light may need as much as a city block of real estate.
Baker agreed that $125 million for a proton beam unit is a big pill to swallow for something whose capabilities are still being discovered. However, he pointed out that a patient with cancer in the spine may mean the difference between surviving as a quadriplegic, having received radiation therapy, and surviving to live a normal life, having received proton beam therapy.
With the high cost of all this technology and the return on investment considerations, how does the private practitioner compete? His point is to share, not only the risk, but the potential opportunity in the technology.
He says he is “seeing more and more requests for partnerships and joint ventures, which can work very well if people are realistic about their expectations and goals. Partnerships can be structured in many different ways depending on the practice’s needs and the legal considerations.”
“Of course, the challenge is how to take advantage of the new technology without interrupting patient and revenue streams. Unfortunately, there really is no easy or inexpensive answer for this yet. If your technology is too old to accept an upgrade, the only option that allows for an uninterrupted work flow is to build a new facility.”
“Granted, that’s expensive and complex,” he says, “but it allows the new technology to be integrated, and it positions the practice for the future, while delivering better service to patients.”