Proton therapy centers: 14 up, 1 down, and 12 to go

A new story on the Kaiser Health News web site has provided us with a relatively neutral perspective on access to proton beam radiation therapy (PBRT) in America (today and tomorrow).

Basically, the KHN story tells us that there are now 14 functional proton therapy centers in the USA, and 12 centers under construction, and that one of the early centers (at Bloomington, Indiana) is shutting down because it has not proven to be cost-effective and it would be too costly to upgrade the facility to meet the latest quality standards.

We already know that some of the newer centers have been having a hard time achieving their revenue goals because many payers are yet to be convinced that the effectiveness and safety of PBRT is significantly higher than other forms of radiation therapy for the treatment of high volume forms of cancer (prostate cancer included). It is also likely to be true that expanding use of active surveillance as a management strategy for low-risk forms of prostate cancer (and other cancers) may be cutting the size of the potential market for all forms of radiation therapy as first-line treatment for low-risk disease.

Despite this … three different centers, all within about 40 miles of each other, are building new PBRT facilities here on the east coast (at MedStar Georgetown University Hospital, at Johns Hopkins Medicine Sibley Memorial Hospital, and at the University of Maryland). Even though this is a highly populated area, one really has to wonder whether all three centers are going to be cost-effective (even if they can prove to be clinically valuable). We are led to believe that the PBRT center at the University of Pennsylvania just a few miles up the road has been struggling to meet its financial goals.

Our view is that if the advocates for PBRT as a safer and more effective form of treatment for localized prostate cancer than other forms of radiation therapy want payers to be convinced that PBRT really is better than modern IMRT, they need to become a great deal more active in convincing patients to participate in the ongoing clinical trial that has been designed to prove this point.

9 Responses

  1. Thanks again for being on top of vital health care news. We would think if ever there was a time to unlock the 1000s of proton therapy outcomes and prove their advertising would be now in the face of the information about insurance companies dropping coverage for the same reason. Of course if these outcomes do not support the highly questioned clinical studies and are not released, then, if I had been thinking about investing, I would think again.

    Sorry I have not been back about 7 T MRIs; in bed recovering from back surgery, but the role of imaging in changing the way we look and treat prostate cancer has moved beyond my expectations.

    God Bless

  2. Dear kEN;

    Alas, the only PBRT center that could ever have accumulated the “1000s of proton therapy outcomes” data and report on them would have been Loma Linda, and they have done a spectacular job of failing to accurately compile and report such data over the past 20 years!

    Although 7 T MRI machines have been around for quite a while, it is my understanding that these machines have been used entirely for non-clinical research purposes to date, and not for clinical purposes at all.

  3. Sorry. I cannot get more info out until I can get to the computer. The University of Minnesota has done 15 prostate MRIs and two more universities are in the works. It would make for a huge generation of refurbished 3 T’s and pricing to open the flood gates.

    God Bless


    Even if further proton effectiveness reports support equivalence with well-done IMRT as did the Jacksonville proton report a while back, the wisdom of active surveillance for low-risk patients may be posing another problem for proton centers in addition to reducing the number of potential customers: that problem is unnecessary accuracy for a key target population of patients with significant prostate cancer that includes higher-risk characteristics, especially spread.

    The big selling point for proton, even though somewhat controversial, has been precisely focused targeting, sort of like the sniper rifle approach to prostate cancer. Arguably that accuracy could work well for patients with quite limited disease, the kind that is predominant in low-risk folks that are often best served by active surveillance. However, when you move to more widely spread disease, including a suggestion of disease beyond the prostate in the pelvis, such accuracy cedes position to a more shotgun type approach, which IMRT is quite good at (as well as achieving high accuracy when needed). For my own case, it was clear early that a proton approach would have had to have included some photon radiation to generally treat any stealthy cancer in the pelvis. My impression is that patients with some higher-risk features will often need some photon radiation, such as IMRT, even if some or most of the work is done with protons. I am not aware of studies of this issue of combining protons and photons.

    I’m thinking any supposed advantage of protons would get pretty marginal in patients who need both therapies, especially with the very low risk of side effects with modern, sophisticated IMRT technology.

  5. Some of the proton units available now are smaller and cheaper than older models. Some new systems cost closer to 30 million instead of 150 million dollars.

  6. Robert:

    That is true, and I believe the one at the University of Maryland will be a $30 million facility … but the number of patients you can treat at such a facility is fewer, so the revenue stream cannot even theoretically be as high.

  7. The problem lies with proton therapy. There are no outcome data which even suggest proton therapy for prostate cancer is any better than seeding or external radiation. You get all the same side effects and, like other forms of radiation, it takes time for you to become impotent or incontinent or develop any number of radiation side effects. Does the high cost justify the results? At this time, its a resounding no.

    Ron Rosen, MD

  8. The shame in urology is that the main alternatives for localized prostate cancer are cut it out or radiate it. The very same alternatives available to our parents. Urologists themselves will tell you how much progress breast cancer treatment for women has made in 10 years and compare it with the dismal results in urology — especially for localized prostate cancer.The amounts of money endowed to research account for only part of the story. The Kingdom of Research in the USA is old, a heavily guarded bastion of academia, antiquated and a tremendous waste of tax dollars. If you knew the numbers of studies and the money and wasted man-hours which went into such poorly planned, poorly focused work where either incorrect or needless data were collected, it would bring tears. Without well done outcome studies the only people to benefit may be the people who own the proton generator and those who charge their patients for its very unknown benefits. Remember how clean and focused it’s supposed to be versus the real time side effects incurred.

    Ron Rosen, MD

  9. Well, here comes another “latest” as to coverage for proton beam therapy for men with prostate cancer: “Insurers hesitant to cover proton beam Tx.”

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: