Proton therapy is now a punch line

[Gfunk6]

In a completely unrelated article about a podiatrist charging $180k for a simple hammertoe fix (usually costs $3k), I found the following gem of a quote.

“I’m stunned,” said Dr. John Santa, a director of Consumer Reports Health. “Did they use a proton beam for this?”

Full article: http://nypost.com/2014/03/16/180k-bill-for-simple-foot-procedure-sparks-payment-fight/

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[subatomicdoc]

I just wrote up something on the cost portion, but also pointing out protons can miss.
http://radiationnation.com/opinion/proton-therapy

 

[stems]

In a completely unrelated article about a podiatrist charging $180k for a simple hammertoe fix (usually costs $3k), I found the following gem of a quote.



Full article: http://nypost.com/2014/03/16/180k-bill-for-simple-foot-procedure-sparks-payment-fight/

Why is it that most who don't have Protons and are not about to aquire it bag on Proton Therapy. It is a very precise modality of treatment and is likely to part-take a greater role in treatments once the technology matures. I know its not completely mature yet, but I guarantee you a multiple field IMPT plan in the future would give a much better dose conformity than IMRT in the future. Of course a 1 field proton therapy plan won't be as good as a very sophisticated IMRT plan but we should compare apples to apples...

 

[Haybrant]

Why is it that most who don't have Protons and are not about to aquire it bag on Proton Therapy. It is a very precise modality of treatment and is likely to part-take a greater role in treatments once the technology matures. I know its not completely mature yet, but I guarantee you a multiple field IMPT plan in the future would give a much better dose conformity than IMRT in the future. Of course a 1 field proton therapy plan won't be as good as a very sophisticated IMRT plan but we should compare apples to apples...

Entirely agree with this. Protons are the future of our field. Compare apples to apples

 

[medgator]

Why is it that most who don't have Protons and are not about to aquire it bag on Proton Therapy. It is a very precise modality of treatment and is likely to part-take a greater role in treatments once the technology matures. I know its not completely mature yet, but I guarantee you a multiple field IMPT plan in the future would give a much better dose conformity than IMRT in the future. Of course a 1 field proton therapy plan won't be as good as a very sophisticated IMRT plan but we should compare apples to apples...

Yet we have centers doing laterals for protons now and justifying the price tag based on that perceived superiority over imrt without the data to back it up

 

[medgator]

Entirely agree with this. Protons are the future of our field. Compare apples to apples

Are they? Do we know enough to say they are clearly superior for all disease sites and indications (ignoring for a minute the cost difference)?

The cost jump from 3D to imrt was a small step compared to the chasm of going from imrt to protons. With such a big difference, you're better believe that the data better be there before we see widespread adoption and validation by payors

 

[Haybrant]

Are they? Do we know enough to say they are clearly superior for all disease sites and indications (ignoring for a minute the cost difference)?

The cost jump from 3D to imrt was a small step compared to the chasm of going from imrt to protons. With such a big difference, you're better believe that the data better be there before we see widespread adoption and validation by payors

um, not every disease site. Is IMRT better than 3D for every disease site?

 

[medgator]

um, not every disease site. Is IMRT better than 3D for every disease site?

I wasn't trying to imply that. I just said the bar was probably set lower for imrt because of the cost differences.

The statement I was responding to implied protons are the future of our field.

 

[stems]

Yet we have centers domeng laterals for protons now and justmefymeng the prmece tag based on that percemeved supermeormety over memrt wmethout the data to back met up

These are early adopters and I give my hats off to them for their part in advancing our field. I just think physicians in our field should be less petty and stop criticizing an emerging technology.

 

[subatomicdoc]

SDN seems to have some snafus with pronouns. odd!

 

[stems]

SDN seems to have some snafus with pronouns. odd!

didn't write "give me my hats off" and it won't let me correct it

 

[stems]

SDN programmers change all Is to mes reminds me of Lord of the rings...

Oh i get it , Appril Foools

It won't let me even spell the month correctly and autochanges it

 

[medgator]

It's probably an April Fools joke (A P R I L F O O L S J O K E)

 

[medgator]

Co-authored by an MD who works at a proton therapy center in this month's red journal.....

http://www.redjournal.org/article/S0360-3016(14)00199-0/abstract

Conclusion:

The expansion of PBT centers in the US is not sustainable under the current reimbursement model. Viability of new centers will be limited to those operating in larger regional metropolitan areas, and few metropolitan areas in the US can support multiple centers. In general, 1-room centers require captive (non–PBT-served) populations of approximately 1,000,000 lives to be economically viable, and a large center will require a population of >4,000,000 lives. In areas with smaller populations or where or a PBT center already exists, new centers require subsidy.

 

[Gfunk6]

http://www.redjournal.org/article/S0360-3016(14)00199-0/abstract

Translation: Don't build any more proton centers in Indiana!

 

[OTN]

Translation: Don't build any more proton centers in Indiana!

In defense of the Bloomington, Indiana proton facility, it was a functioning cyclotron for physics research and was converted to a clinical machine after high-energy physics passed it by. It was used to treat uveal melanoma back in 2000 when I was in undergrad there. For some reason they didn't publicize/develop the program very extensively at all in the early days.

 

[napoleondynamite]

Until such time that proton centers begin to aggressively accept appropriate patients, they will continue to be a punch line. They don't want the re-irradiation of the H&N patient where protons could have a dosimetric advantage to the spinal cord. They don't want the underinsured pediatric patient. They screen all of these patients out and only accept the most favorable patients to their centers. The low-risk prostate cancer patient that would be treated just as well, perhaps better, with IMRT.

 

[jcradonc]

Protons might not be best for prostate...

http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(14)70304-3/fulltext

But they seem better than IMRT in some HNSCC

http://newsnetwork.mayoclinic.org/d...anced-head-and-neck-cancers-mayo-study-finds/

 

[medgator]

Protons might not be best for prostate...

http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(14)70304-3/fulltext

But they seem better than IMRT in some HNSCC

http://newsnetwork.mayoclinic.org/d...anced-head-and-neck-cancers-mayo-study-finds/

I'll keep that in mind the next time I see a paranasal sinus or nasal cavity cancer. I see a lot more prostate CA than that though.

 

[Gfunk6]

Here we go again!

http://www.americanprogress.org/iss...radiation-therapy-wastes-millions-of-dollars/

 

[medgator]

Here we go again!

http://www.americanprogress.org/iss...radiation-therapy-wastes-millions-of-dollars/

Yet despite this lack of apparent clinical benefit, almost 80 percent of Medicare’s spending on PRT goes toward prostate cancer treatment.

Didn't know that...

 

[lazers]

Yet despite this lack of apparent clinical benefit, almost 80 percent of Medicare’s spending on PRT goes toward prostate cancer treatment.

Didn't know that...

You could say the same thing for 90% of what NASA does. Investing in new technology will allow our field to progress. I'm glad we have early investors in proton therapy.

 

[medgator]

You could say the same thing for 90% of what NASA does. Investing in new technology will allow our field to progress. I'm glad we have early investors in proton therapy.

That's fine. It's their risk to take. I think it should be reimbursed no more than IMRT until an actual benefit can be discerned.

 

[Haybrant]

You could say the same thing for 90% of what NASA does. Investing in new technology will allow our field to progress. I'm glad we have early investors in proton therapy.

would agree. IMPT will be quite impressive when it is available. Can anyone speak to why this is technologically such a challenge? Is it collimating the proton beam and dealing with the bolus is just such a difficult barrier? Beam on time too burdensome?

Historically better technology wins out. Doesnt mean it doesnt need to be proven or further developed but all that low dose for conformality is a problem. It is easy to criticize but if it were independent of cost (yes, it is not) for most external plans you would probably choose for yourself or family to get IMPT/PBS for most sites other than prostate (and assuming your survival prognosis isnt short)

 

[thesauce]

Not really, lets look at the common malignancies:

1) Prostate Cancer- Nope, and for early stage I'd take brachy over IMPT

2) Breast- Again, no proven benefit with early proton APBI trials having higher toxicity. Cardiac sparing is probably equivalent or better with IMRT, prone, breathing for left sided

3) CNS- in adults, number one overall is mets and primary high grade glioma, don't see much benefit there

4) Lung- Phase III going on right now i think, but really can't see much of a benefit in Stage III


Investing in new technology is important but it shouldn't be done in a way that throws the whole specialty under the bus which is what proton centers and their reimbursements have done in many ways. If you want to justify the significantly higher costs, first prove a clinical not just dosimetric benefit that can justify the costs outside of peds/base of skull/re-treats.

I don't understand the last part. I could be wrong, but doesn't CMS re-evaluate individual codes each year? For instance, if they think protons are reimbursed too much - they cut that. You seem to imply that they cut IMRT when protons are reimbursed too much. We don't have a specialty-specific cap (that I know of). We could be as big as cardiology (in theory) if we developed more techniques and codes.

Also, it's hard to show a clinical benefit without treating patients first. And you can't treat patients for free. I do believe that early centers like Loma Linda could have done a lot more in terms of proving clinical benefit, but later centers like Penn are doing a better job, I feel.

*Not trying to be argumentative here, Wagy. You're a very smart guy and a great doc (yes, I know you).

 

[medgator]

Also, it's hard to show a clinical benefit without treating patients first. And you can't treat patients for free.

That's fine. We should reimburse proton centers who are treating prostate CA patients on a clinical trial or as part of a multi-institutional registry, and should do so with "reference pricing"

Some relevant links:

http://jco.ascopubs.org/content/32/15/1540.full

http://www.medpagetoday.com/Radiology/TherapeuticRadiology/46170

 

[thaddeus]

Apropos to this thread, saw this ad while getting my news this morning (look at bottom of screenshot). Note I do not live anywhere near San Diego, so this is apparently a national ad campaign to get folks to come to SD for their prostate treatment. Clearly investors in proton therapy are spending their money wisely to innovate and move the field forward.

 

[OTN]

Well, when you build a 5-gantry machine costing in the ballpark of $200+M only 90 minutes away from Loma Linda, I guess you have to look outside of San Diego in an attempt to not go bankrupt.

 

[medgator]

Saw this in the news last week, guess some insurers are denying protons for anything

Publix, Florida Blue sued over denial for cancer treatment at Mayo Clinic

 

[Phantom1]

Now that some institutions/insurers are charging/paying the same for protons, have we entered a new era of proton therapy where budgets must be made assuming similar reimbursement as photons? Will this change the incentives, potentially favorably, by forcing manufactures to cut costs and institutions to build more reasonable sustainable centers? There are still significant technological benefits to proton therapy, especially pencil beam, over time wondering if we can use this technology more responsibly...

 

[Reaganite]

Saw this in the news last week, guess some insurers are denying protons for anything

Publix, Florida Blue sued over denial for cancer treatment at Mayo Clinic

Would be nice to know who the doc was that actually had the gall to allow this family to pay 200k out of pocket instead of just offering imrt. He/she is the the real @#$! here.

 

[Palex80]

I don't get it...

The Mayo clinic charges the same amount for proton treatment as for IMRT?

How can they ever hope to pay back for the investment? IMRT for olugodendroglioma or any other brain tumor in the region of 60/2 in the US costs about 60k?

 

[medgator]

I don't get it...

The Mayo clinic charges the same amount for proton treatment as for IMRT?

How can they ever hope to pay back for the investment? IMRT for olugodendroglioma or any other brain tumor in the region of 60/2 in the US costs about 60k?

I'm guessing the idea is to make proton therapy more palatable for the insurers they contract with, as many refuse to cover proton therapy for common indications like prostate, if they do at all...

 

[BobbyHeenan]

Would be nice to know who the doc was that actually had the gall to allow this family to pay 200k out of pocket instead of just offering imrt. He/she is the the real @#$! here.

This goes on quite a bit in my experience. When you sell the therapy so hard to the patient(s) detailing the virtues of protons, the patients are so convinced it is so superior to photons that they'll gladly dip into 401k or whatever to pay for it when insurance denies it.

I've seen it in prostate, breast, and GBM patients over the past two years (patients paying cash for protons). When newspapers or other lay-person publications hear the story it sounds like it's criminal from the insurance companies, but often times as a rad onc I'm sitting there having the same kind of questions you are.

Something in this story seems odd though - if insurance pays the same for proton/photon, then why was proton not approved? Maybe it's a principle thing, like their official policy is to only cover proton for certain indications, even if it's paying the same. It's often very hard to figure out the "real story" from these types of articles.

 

[Palex80]

I'm guessing the idea is to make proton therapy more palatable for the insurers they contract with, as many refuse to cover proton therapy for common indications like prostate, if they do at all...

In Europe you wouldn't be allowed to do that. I am not sure how it's regulated in the States, but where I live you are not allowed to deviate from the official price tag.
It's considered unethical.

 

[radiaterMike]

In Europe you wouldn't be allowed to do that. I am not sure how it's regulated in the States, but where I live you are not allowed to deviate from the official price tag.
It's considered unethical.

There is no official price tag. The hospital/clinic negotiates reimbursement with the insurers.


Sent from my iPhone using SDN mobile

 

[evilbooyaa]

They charge the same as IMRT, and the insurance didn't cover it?

Does this mean they wouldn't have allowed photon IMRT in a 30 something year old with a brain tumor?

I'm fine with places using their protons if they charge the same as something known to be good enough. I agree that the insurance company should have paid this if the asked reimbursement was equal to photon IMRT.

 

[Gfunk6]

Part of it has to do with the trust you place in your treating physician. I recently had a patient from a developing country with medically refractory trigeminal neuralgia who saw me for SRS. I told her to do it in her home country because the top tier centers had excellent hardware/staff expertise. Plus out of pocket expense would be WAY less than in US.

To my surprise they came back to me two weeks later and requested that I do it. Two of her kids are in tech and quite wealthy and were willing to pay cash for it. Should I have refused? I didn't.


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[medgator]

Proton Therapy Not Better Than IMRT in Lung Cancer
Medscape: Medscape Access

This finding "challenges the assumption on the part of many that protons would certainly be superior and emphasizes the importance of evidence-based medicine and randomized trials," comments Feng-Ming (Spring) Kong, MD, from the Indiana University School of Medicine, Indianapolis, in an editorial that accompanies the publication of the findings.

"Personally, as a radiation oncologist, I would not recommend proton therapy for NSCLC outside a clinical trial setting until a clinical benefit is demonstrated in a prospective randomized study," she writes.

http://ascopubs.org/doi/abs/10.1200/JCO.2017.74.0720?journalCode=jco

 

[Gfunk6]

Proton Therapy Not Better Than IMRT in Lung Cancer
Medscape: Medscape Access



http://ascopubs.org/doi/abs/10.1200/JCO.2017.74.0720?journalCode=jco

Dammit Gator, you beat me to the punch!

Pretty much what one would expect - Protons > IMRT in terms of reimbursement and that's about it.

 

[BobbyHeenan]

Dammit Gator, you beat me to the punch!

Pretty much what one would expect - Protons > IMRT in terms of reimbursement and that's about it.

Nominal improvements in dosimetry don't always translate to clinical benefit. I've noticed though the tag line from the proton components is "no dose of radiation is ever safe," so the heart dose here will continue to drive the party line I bet - extrapolating from 0617 (though I suspect heart dose may correlate with mediastinal involvement or tumor size)....

 

[evilbooyaa]

The argument will be "but passive scattering is old proton, our new pencil beam method is way better, so protons are still better!"

I think IMPT may eventually show some benefit if people can minimize the uncertainty, but I won't pretend I know a ton about proton dosimetry in terms of their various uncertanties.

I wouldn't want a higher V20 lung for a lower heart dose with an exponential increase in cost.