What happens when every hospital wants a proton beam facility?

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That’s the question asked by Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston.

I keep bringing up proton beam therapy in my talks to journalists for the same reasons Levy raises in his blog post, “Protons killing cancer and our budget”:

“…we see the medical arms race at work again.

These are huge and very expensive machines, costing upwards of $150 million dollars. At that price, there should only be a very few in the entire country. Yet, as noted in a recent paper by Anthony Zietman, Michael Goitein, and Joel E. Tepper in the Journal of Clinical Oncology, “In the United States alone, seven centers are in operation and at least 10 more are likely to come into operation in the next decade.” J Clin Oncol 28:4275-4279

mapbtn_928.gif Here’s the map of existing facilities and others currently under development or construction, as posted on the web site of the National Association for Proton Therapy (NAPT). What will this look like in a few years?

There is no way this makes sense. As noted, the main value of these machines is in treating certain distinct forms of cancer. The problem occurs when one is purchased as a prestige item. Since there is not enough demand for its use for the appropriate cases, it starts to be used for other types of cancer that would ordinarily be treated with traditional forms of radiotherapy.”

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Louis Memoli

November 10, 2010 at 5:58 pm

Proton Beam Therapy (PBT) is one of the most, if not the most expensive technology to ever come along in medicine. I was directly involved with the center at MD Anderson and the negotiations at several other centers and I can tell you that these projects are quite complex with decisions being made at the board level. In theory, PBT is far superior than external beam radiation therapy (EBRT) because of the dose distribution of particles compared to x-rays. About 8 years ago, interest in PBT started to blossom because imaging technology had reached a point where tumor volumes could be better defined and and with better tumor volume definition, higher precision therapy could be used. PBT spares healthy tissue in the path before and deposits all of it’s energy in the target (tumor) with no exit dose. This is the main distinction between protons and x-rays. PBT could therefore treat just the target and not irradiate healthy surrounding tissue thus allowing for shorter treatment regimines (fewer treatments) at higer doses thus having a more efficient mode of therapy. But at the time the clinical database for PBT was only 50,000 or so patients treated worldwide since the technology was invented, so much of the thinking was based on logic and not evidence. Now, with more PBT centers in operation there are many papers being written and the clinical evidence is showing that PBT is effective for treating a variety of cancers and most notably better for treating children but the exploration has just begun. However, some of the newer types of linear accelerators are coming close to PBT in terms of dosimetry but until we have sufficient time to assess the relative effectiveness of both PBT and EBRT, the ‘medical arms race’ will ensue. Every prominant cancer center (or wanna be) must offer the latest and greatest treatment modality – its good for business. Unfortunately, the financial success of a PBT center rests on patient throughput. With reimbursment likely to continue dropping, a center will need to run 2 full shifts with maximum patient throughput… the third shift is needed for physics and engineering because these systems require a lot of attention. Should the proliferation of PBT centers reach the point where there are not enough patients to pay the bills (like in a few places where there are 2 PBT centers in one city), I fear that patients will be referred for PBT treatment when, for their condition, traditional radiation oncology would have been adequate.
While the price tag for PBT has been upwards of $150+ million, things are starting to change as the industry begins to take shape, as technology advances, and as competition grows. New systems are coming on board at half or a third the cost. These are small, one or two room systems. Getting the price down to $50 million (equipment + construction) is still a lot of money but not that far above the cost of a traditional radiation oncology center. Time will tell whether these massive investments have been worth it. In the meantime, some centers are talking about carbion ion and other types of particle therapy… where $150 million for a project would sound cheap! And again, the clinical evidence for particle therapy is sketchy at best. I am entirely in favor of finding better ways to treat cancer and I love technology but I would think that PBT would have been relegated to NCI centers until such time as its efficacy had been determined… but hey, this is America where capitalism is king.

Susan Fitzgerald

November 15, 2010 at 1:13 pm

Here’s something else that happens when everybody wants a $150 million piece of equipment: your insurance premiums go up, something this hospital CEO doesn’t mention. Yes, I work for a health insurance company. I’m keenly aware of people bashing insurers for not controlling costs on the one hand, while bashing them for strategically covering treatments with the best outcomes (which sometimes means lowest cost, sometimes not).
This is why I really appreciate the work of this site, for challenging reporters to ask the 10 questions posted here about both effectiveness and cost.