Gizmodolatory and the future of PBRT

An article in the August 10 issue of The ASCO Post has recently asked the question, “Is proton-beam therapy facing a difficult future?

The article deals with the degree to which the financial model on which almost every proton beam radiation therapy (PBRT) center in the USA has been developed is one in which two out of every three claims for treatment was supposed to be for treating prostate cancer and about 80 percent of the centers’ revenues were going to come from Medicare. However, …

These business assumptions failed to take account of the increasing number of men — and their urologists — who would start to see active surveillance as a highly appropriate management strategy for low-risk forms of prostate cancer, and the unwillingness of some major payers to cover the costs of PBRT, given the lack of clear evidence that PBRT is actually either more effective or safer than high quality IMRT.

Medicare is now reimbursing centers at about $32,000 for a course of PBRT for a prostate cancer patient as opposed to $19,000 for a course of IMRT, and one can be pretty sure that most private insurance companies have managed to arrange similar financial rates if they are willing to pay for PBRT at all. In December 2014, as we have previously mentioned, the Indiana University Proton Therapy Center closed down because of the center’s “untenable financial losses”.

Ronald Piana’s article in The ASCO Post also raises the whole issue of “gizmodolatory” — our compulsive desire to believe that bigger, newer, and flashier technologies simply must be “better” than older and less glitzy methods for the treatment of relatively common healthcare problems like prostate cancer. While the PBRT center at Loma Linda may well have been at least as effective and probably safer than the outdated 3D-CRT forms of radiation therapy being widely used in the 1990s, by the early 2000s PBRT was starting to have to compete with much more accurate forms of photon-based radiation, based on IMRT and IGRT. The rules of the game had already changed before almost anyone else had actually got into it.

The “New” Prostate Cancer InfoLink has long argued that we have been over-investing in PBRT; building far more PBRT centers than could be justified by market need; and failing to deliver compelling, “real life” data to support the theoretical benefits associated with PBRT in the treatment of localized prostate cancer.

PBRT certainly holds benefits for the treatment of a number of relatively rare forms of cancer … and it may be highly appropriate in the treatment of a set of carefully selected prostate and breast cancer patients too. It will be a shame if a dozen or more PBRT centers and several billions of dollars have to be sacrificed to keep open the four or five centers that can probably be justified, but that may be the price we are all going to be paying. Your sitemaster would not, today, want to be the person at the Mayo Clinic who made the decision to build two of the most expensive of these centers, in Rochester, MN, and Phoenix, AZ, a few years ago. Neither of these two centers has actually started to treat patients yet, and whether they are going to be (or indeed ever were going to be) financially viable is starting to look increasingly doubtful.

5 Responses

  1. I saw a paper last year by U of FL Proton center, showing excellent results with minimal side effects. I take them at their word

  2. Other threats to the financial viability to proton centers include the possible development of in-body radiation sources coupled to prostate cancer seekers, such as an isotope of lutetium coupled to an antibody for the PSMA molecule, as discussed here though still barely in the investigational stage, and a far cheaper and simpler way of producing protons, which I’ve heard about in a theoretical discussion.

  3. From an article on the PracticeUpdate web site:

    “In our study thus far, with a follow-up period of approximately 2.5 years after PT and 4 years after IMRT, there do not appear to be statistically significant differences in genitourinary or gastrointestinal side effects among patients who received PT and IMRT for prostate cancer. Having said this, it will be critical for us to continue to observe these patients and analyze chronic side effect rates, as well as important outcomes such as disease-free survival.”

    In addition, Jon Nowlin of Nevada provided these very sensible remarks and conclusions in message on an online prostate cancer support list back in March 2013:

    “Protons vs Photons– there is no simple answer.

    “It is true that there are no compelling and objective comparative studies showing that proton radiation is more effective with respect to prostate cancer control than other modern radiation treatments such as IMRT and SBRT.

    “Objective comparisons of side effects after treatment are somewhat ambiguous despite the apparent overwhelming satisfaction of prostate ‘graduates’ from proton treatment.

    “Some studies show about the same level of side effects as conventional ‘photon’ radiation. Some show a bit more severe side effects. …

    “So, why are there so many proton centers and more being built? At the 2012 Prostate Cancer Research Institute Conference, Dr. Michael Steinberg, Chair of the UCLA Dept. of Radiation Oncology was asked that question. In addition to offering state-of-the-art ‘photon’ IMRT and SBRT facilities, UCLA is planning to build a proton facility. But, he had just stated that there was no demonstrated benefit of the more expensive proton treatment over today’s IMRT or SBRT radiation for prostate cancer. His response was that the UCLA Department of Radiation Oncology was one of the premier institutions for treatment of pediatric cancers, and, for children, there is a demonstrated advantage to using proton radiation compared to conventional ‘photon’ radiation to reduce the radiation burden to young tissues. He also said that there was some advantage for proton radiation for small discrete ‘hard tissue’ cancers such as brain tumors. But, he repeated that he saw no advantage for proton radiation over conventional IMRT or SBRT radiation for larger soft tumors such as prostate cancers. He also acknowledged that there is a significantly larger customer base of prostate cancer patients than for other types of cancer, and he had no doubt that the UCLA proton facility would be offered to prostate cancer patients requesting proton treatment in order to spread out the income base to pay for the more expensive investment in a proton facility. That’s not a sinister attempt to fiscally ‘gouge’ patients; just an honest statement of the current market reality.

    “I have yet to talk to any man who has been disappointed in proton treatment for prostate cancer. In 2006 as part of my intensive research into prostate cancer treatment options, I had a consult with Dr. Sidney Jabola at Loma Linda’s proton center. I was very impressed with the professionalism and caring presentations by all the Loma Linda staff during that consult. However, my (and my wife’s) decision in early 2007 after consults on all treatment options was to pursue Active Surveillance.

    “Since then my continuing research into treatment options has not found any compelling evidence that proton radiation is superior to modern IMRT or SBRT radiation for prostate cancer. This is not saying that it is worse than the alternatives, just that there is no overwhelming objective evidence that it is better. It is, however, demonstrably more expensive with respect to cost and, if one is not close to a proton facility, time.

    “Our personal goal for my prostate cancer treatment is to, within our fiscal resources, maximize the probability of my prostate cancer control while minimizing impacts on our quality of life. Our personal conclusion is that there are, for me, better alternatives than the current capabilities of proton treatment. Certainly, other men and their partners may come to a different conclusion.

    “Ultimately, every one of us facing decisions on prostate cancer treatment need to fully explore all the options and make a personal decision based on our specific cancer staging and our quality of life goals. …”

  4. This last comment sums up things very well. I find it extremely upsetting that proton beam proponents have been marketing the treatment for prostate cancer for so many years without any clear evidence it is better. Why should Medicare pay nearly twice as much money for a treatment offering no clear advantages in prostate cancer? Shame on the proton beam community for never doing a study that would allow a real comparison with IMRT!

  5. Dear Gerry:

    To be fair, some in the proton beam community have been trying to do such a study for a while … others, not so much!

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