Protons in the news

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
Members don't see this ad :)
RickyScott said:
Maybe it was retrospective experience?
Click to expand...
radoncgrad2019 said:
yeah probably.
Click to expand...
They did it a lot. Not sure there is a randomized Imrt vs 3d trial in prostate?! (If there is I’m in for a good education today. )

E534AD81-04FF-42D6-B4BB-36AB7D86F4A9.png

E534AD81-04FF-42D6-B4BB-36AB7D86F4A9.png
 
  • Like
Reactions: 1 user
IMRT is used a lot in patients in many cases because it makes dosimetric sense, without significant evidence that it will decrease serious clinically significant toxicities or improve important oncologic endpoints. Likewise in my book, things like IMPT or passive scatter should be used in those clinical situations. It takes a bit more work on the physics/dosimetry side to put together a complex safe proton plan, and that should be accounted for in terms of pay. Ok say thats a no go, then fine pay as IMRT and solve this issue once and for all. Let’s put it behind us. All of these things should be looked at. Its not constructive for our field to not look into it.

will more protons be used in the future? Nobody really knows. Fascinating IMPT vs IMRT trial ongoing in oropharynx. The Steve Lin esophagus study is interesting. The players are playing and if they come up with data, perhaps that will be the case. Nobody really knows anyways. Then there’s carbon. The europeans and Japanese multiple centres. Not a single one here in USA. We’ll see about Mayo... game changer? We’ll see what happens...!
 
Last edited:
thecarbonionangle said:
IMRT is used a lot in patients in many cases because it makes dosimetric sense, without significant evidence that it will decrease serious clinically significant toxicities or improve important oncologic endpoints. Likewise in my book, things like IMPT or passive scatter should be used in those clinical situations. It takes a bit more work on the physics/dosimetry side to put together a complex safe proton plan, and that should be accounted for in terms of pay. Ok say thats a no go, then fine pay as IMRT and solve this issue once and for all. Let’s put it behind us. All of these things should be looked at. Its not constructive for our field to not look into it.

will more protons be used in the future? Nobody really knows. Fascinating IMPT vs IMRT trial ongoing in oropharynx. The Steve Lin esophagus study is interesting. The players are playing and if they come up with data, perhaps that will be the case. Nobody really knows anyways. Then there’s carbon. The europeans and Japanese multiple centres. Not a single one here in USA. We’ll see about Mayo... game changer? We’ll see what happens...!
Click to expand...
Totally agree. With prostate and lung, some of the experience indicates protons are actually worse.
 
  • Like
Reactions: 1 users
RickyScott said:
Totally agree. With prostate and lung, some of the experience indicates protons are actually worse.
Click to expand...
Perhaps. Most of it was passive scatter, i think. It def tells me that the lung V5 is not very important at all, but we already knew that from 0617!

i dont think doing protons in lung makes much sense the majority of cases (Lots of air in lung) , but there are definitely some specialized cases where it may make sense. I see it as a tool in our repertoire.
 
Last edited:
thecarbonionangle said:
Perhaps. Most of it was passive scatter, i think. It def tells me that the V5 is not very important at all, but we already knew that from 0617!

i dont think doing protons in lung makes much sense the majority of cases (Lots of air in lung) , but there are definitely some specialized cases where it may make sense. I see it as a tool in our repertoire.
Click to expand...

would love to know which cases you think it helps!
 
Looking at the recent March 2020 update of 0617, heart V5 was associated with overall survival. I think the best approach to take is to do comparative plans and take into account comorbidities of age etc. In a system
Where i dont have to worry about insurance approval, piles of bs paperwork, id pick the best plan possible (i.e. less heart dose, able to get a higher dose of xrt to a tumor near the spinal cord, etc). it would all be case dependent pretty much for anywhere in the body.

i’ve looked at many beautiful IMRT vs IMPT plans in my day. Sometimes i wouldn’t care if you tossed a coin and picked one. Sometimes you’re pretty damn sure which one you’d want for you or your family.
 
  • Like
Reactions: 1 user
RickyScott said:
Maybe it was retrospective experience?
Click to expand...
radoncgrad2019 said:
yeah probably.
Click to expand...

No improvement in patient -reported outcomes, but there was a difference in physician-reported toxicity from 0126.

The improved endpoint is G2 combined, although likely underpowered and variations in IMRT planning meaning it washed out on multivariate.

www.ncbi.nlm.nih.gov

Preliminary toxicity analysis of 3-dimensional conformal radiation therapy versus intensity modulated radiation therapy on the high-dose arm of the Radiation Therapy Oncology Group 0126 prostate cancer trial - PubMed

Intensity modulated RT is associated with a significant reduction in acute G2+ GI/GU toxicity. There is a trend for a clinically meaningful reduction in late G2+ GI toxicity with IMRT. The occurrence of acute GI toxicity and large (>15%) volumes of rectum >70 Gy are associated with late rectal …
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
FWIW
RCT IMRT vs 3D from Brazil

pubmed.ncbi.nlm.nih.gov

Intensity-modulated radiotherapy reduces toxicity with similar biochemical control compared with 3-dimensional conformal radiotherapy for prostate cancer: A randomized clinical trial - PubMed

IMRT reduced the delivery of significant radiation doses to the bladder and rectum using a similar target volume. This dosimetric advantage resulted in a lower rate of acute/late grade ≥ 2 GI and GU toxicity for IMRT compared with 3DCRT. Cancer 2016;122:2004-11. © 2016 American Cancer Society.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
  • Like
  • Love
Reactions: 1 users
I think if it was my body I would chose the prostate/pelvis plan on the left
1589392581860.png
 
  • Haha
Reactions: 1 user
Members don't see this ad :)
I'd take neither. Don't treat my nodes unless they are pathologically enlarged
 
  • Like
Reactions: 3 users
  • Like
Reactions: 1 user
scarbrtj said:
The ‘ol “There is no clinical indication for even one picogray of dose outside the target!” Herman Suit play. Well done.
Click to expand...

they should do a a netflix special called “proton king”, many people would be featured including Cox , Suit and all the proton playas
 
  • Haha
Reactions: 1 user
I think one significant issue with protons is the dosimetric modeling and calculations. I simply dont think we model the RBE accurately especially at the brag peak for each particle, and certainly not at interfaces of tissues with different densities, ie Air/Bone. Thus I think the plan we see on the screen is not exactly what the tissues are receiving and there are likely significant “biological hot spots” which can result in toxicity and morbidity.

Its interesting to think that this problem could be solved with a software upgrade and better mathamatical modeling....
 
  • Like
Reactions: 2 users
Phantom1 said:
I think one significant issue with protons is the dosimetric modeling and calculations. I simply dont think we model the RBE accurately especially at the brag peak for each particle, and certainly not at interfaces of tissues with different densities, ie Air/Bone. Thus I think the plan we see on the screen is not exactly what the tissues are receiving and there are likely significant “biological hot spots” which can result in toxicity and morbidity.

Its interesting to think that this problem could be solved with a software upgrade and better mathamatical modeling....
Click to expand...

Might have a role for advancements in phantoms and in vivo dosimetry verification as well, but I’m not a proton guy. Just refer. Haha.
 
HardenedBeam said:
I think if it was my body I would chose the prostate/pelvis plan on the left
View attachment 306138
Click to expand...
The real question isn't which you'd pick with all else equal.

The question is would you be willing to mortgage your house to get the one on the left over the one on the right?

Edit: just noticed the proton plan is the one on the right. Now I'm not sure I understood what you're saying you'd prefer, but I meant mortgage to get protons over photons.
 
Last edited:
  • Like
  • Haha
Reactions: 4 users
I think the details of this lawyer's case are pertinent. If I read the article correctly, I think it said that prostate cancer had spread to his nodes, i.e. high risk. Prostate cancer when treating gross pelvic nodes, for 70 Gray to a node that's adjacent to bowel, is inherently risky. Maybe more so if your patient is a lawyer, or a doctor.

Few people have seen a proton vs IMRT plan for high risk prostate, but I find the differences pretty striking, both on the axial images and DVH below.

In this particular case of high-risk prostate, the sigmoid colon is getting a Mean Dose of 6.6 Gy with Protons, vs 43.8 Gy with VMAT. The rectum is getting 50 Gy with VMAT as seen below, despite being far away from the nodes. It's simply due to bridging dose. There is no bridging dose with protons, due to no exit dose.

A beam that can stop where you tell it to is fundamentally different. With an entrance dose, but no exit dose, integral dose can be half as much with protons as with X-rays. Note that 70 Gy in 28 proton fractions was the dose used here, not 81 Gy in 45 fx, for those who might think proton centers are just in it for the money.

BTW, this isn't a fancy proton plan. It's basically a 3D-conformal proton plan, with PA and 2 laterals. This is not IMPT nor Proton Arc/VMAT,. The differences between IMPT/Proton VMAT and 3D-Protons is just as striking as IMRT/RapidArc was compared to 3D-CRT, and we are only scratching the surface.

We often think that low dose bath doesn't matter, but we know that it does, e.g. for pneumonitis (V20), heart (V5), marrow (V5), hippocampus (V10), and radiosurgery (V12). We know it's harder to repair a high dose region when surrounded by a low dose bath.

Please look over the images and DVH below, and ask yourself honestly: If you needed radiation tomorrow, which one would you choose?

DVH Triangles = VMAT, Squares = Protons.
DVH colors: Sigmoid bowel = magenta, Rectum = brown, Bladder = orange. Red = Prostate PTV (a little dose was added with protons, which may help w/ high risk)

High Risk Prostate.PNG
High Risk Prostate DVH.PNG
 
  • Like
  • Love
Reactions: 4 users
I would be fine with being treated with the IMRT plan. Doses of 43 Gy to the sigmoid and 50 Gy to the rectum don't bother me at all.

What was the cost of the 70 Gy in 28 fx proton delivery? If proton centers aren't "in it for the money," then why is the Mayo Clinic building a third (3rd) proton machine in Jacksonville?
 
  • Like
  • Haha
Reactions: 2 users
Protons at imrt rates is profitable if you have very high rates. NY times on front page this week said that Mayo Clinic in Florida is reimbursed at 3-4 x Medicare rates by many insurers for outpatient procedures.
 
IonsAreOurFuture said:
I think the details of this lawyer's case are pertinent. If I read the article correctly, I think it said that prostate cancer had spread to his nodes, i.e. high risk. Prostate cancer when treating gross pelvic nodes, for 70 Gray to a node that's adjacent to bowel, is inherently risky. Maybe more so if your patient is a lawyer, or a doctor.

Few people have seen a proton vs IMRT plan for high risk prostate, but I find the differences pretty striking, both on the axial images and DVH below.

In this particular case of high-risk prostate, the sigmoid colon is getting a Mean Dose of 6.6 Gy with Protons, vs 43.8 Gy with VMAT. The rectum is getting 50 Gy with VMAT as seen below, despite being far away from the nodes. It's simply due to bridging dose. There is no bridging dose with protons, due to no exit dose.

A beam that can stop where you tell it to is fundamentally different. With an entrance dose, but no exit dose, integral dose can be half as much with protons as with X-rays. Note that 70 Gy in 28 proton fractions was the dose used here, not 81 Gy in 45 fx, for those who might think proton centers are just in it for the money.

BTW, this isn't a fancy proton plan. It's basically a 3D-conformal proton plan, with PA and 2 laterals. This is not IMPT nor Proton Arc/VMAT,. The differences between IMPT/Proton VMAT and 3D-Protons is just as striking as IMRT/RapidArc was compared to 3D-CRT, and we are only scratching the surface.

We often think that low dose bath doesn't matter, but we know that it does, e.g. for pneumonitis (V20), heart (V5), marrow (V5), hippocampus (V10), and radiosurgery (V12). We know it's harder to repair a high dose region when surrounded by a low dose bath.

Please look over the images and DVH below, and ask yourself honestly: If you needed radiation tomorrow, which one would you choose?

DVH Triangles = VMAT, Squares = Protons.
DVH colors: Sigmoid bowel = magenta, Rectum = brown, Bladder = orange. Red = Prostate PTV (a little dose was added with protons, which may help w/ high risk)

View attachment 306861View attachment 306862
Click to expand...
Honestly “believe it or not” I’d choose Xrays because I know em and I love em and they are like a warm old blanket. They’re reliable. Predictable. Not saying “best.” I don’t know. But every momma crow thinks her baby crow is the blackest and it’s a pretty baby crow.

The lowest isoline(s) you show is 20 Gy (and because I’m a pedant I like to remind folks not to capitalize the unit word gray). And then you mention V-whatevers that are all under 20 Gy. At above what dose is it no longer a “low dose bath” and just a bath? The V5 is probably 4000ccs in the X-ray plan and 3000ccs in the proton one. No doubt the total volumes of all isovolume clouds are lower in the proton plan for sure; but clinically important even a little? I just can’t tell ya.
 
  • Like
Reactions: 1 users
IonsAreOurFuture said:
I think the details of this lawyer's case are pertinent. If I read the article correctly, I think it said that prostate cancer had spread to his nodes, i.e. high risk. Prostate cancer when treating gross pelvic nodes, for 70 Gray to a node that's adjacent to bowel, is inherently risky. Maybe more so if your patient is a lawyer, or a doctor.

Few people have seen a proton vs IMRT plan for high risk prostate, but I find the differences pretty striking, both on the axial images and DVH below.

In this particular case of high-risk prostate, the sigmoid colon is getting a Mean Dose of 6.6 Gy with Protons, vs 43.8 Gy with VMAT. The rectum is getting 50 Gy with VMAT as seen below, despite being far away from the nodes. It's simply due to bridging dose. There is no bridging dose with protons, due to no exit dose.

A beam that can stop where you tell it to is fundamentally different. With an entrance dose, but no exit dose, integral dose can be half as much with protons as with X-rays. Note that 70 Gy in 28 proton fractions was the dose used here, not 81 Gy in 45 fx, for those who might think proton centers are just in it for the money.

BTW, this isn't a fancy proton plan. It's basically a 3D-conformal proton plan, with PA and 2 laterals. This is not IMPT nor Proton Arc/VMAT,. The differences between IMPT/Proton VMAT and 3D-Protons is just as striking as IMRT/RapidArc was compared to 3D-CRT, and we are only scratching the surface.

We often think that low dose bath doesn't matter, but we know that it does, e.g. for pneumonitis (V20), heart (V5), marrow (V5), hippocampus (V10), and radiosurgery (V12). We know it's harder to repair a high dose region when surrounded by a low dose bath.

Please look over the images and DVH below, and ask yourself honestly: If you needed radiation tomorrow, which one would you choose?

DVH Triangles = VMAT, Squares = Protons.
DVH colors: Sigmoid bowel = magenta, Rectum = brown, Bladder = orange. Red = Prostate PTV (a little dose was added with protons, which may help w/ high risk)

View attachment 306861View attachment 306862
Click to expand...

i think most people would absolutely want the proton plan but can they afford it? That is the challenge for ion therapy.
 
IonsAreOurFuture said:
I think the details of this lawyer's case are pertinent. If I read the article correctly, I think it said that prostate cancer had spread to his nodes, i.e. high risk. Prostate cancer when treating gross pelvic nodes, for 70 Gray to a node that's adjacent to bowel, is inherently risky. Maybe more so if your patient is a lawyer, or a doctor.

Few people have seen a proton vs IMRT plan for high risk prostate, but I find the differences pretty striking, both on the axial images and DVH below.

In this particular case of high-risk prostate, the sigmoid colon is getting a Mean Dose of 6.6 Gy with Protons, vs 43.8 Gy with VMAT. The rectum is getting 50 Gy with VMAT as seen below, despite being far away from the nodes. It's simply due to bridging dose. There is no bridging dose with protons, due to no exit dose.

A beam that can stop where you tell it to is fundamentally different. With an entrance dose, but no exit dose, integral dose can be half as much with protons as with X-rays. Note that 70 Gy in 28 proton fractions was the dose used here, not 81 Gy in 45 fx, for those who might think proton centers are just in it for the money.

BTW, this isn't a fancy proton plan. It's basically a 3D-conformal proton plan, with PA and 2 laterals. This is not IMPT nor Proton Arc/VMAT,. The differences between IMPT/Proton VMAT and 3D-Protons is just as striking as IMRT/RapidArc was compared to 3D-CRT, and we are only scratching the surface.

We often think that low dose bath doesn't matter, but we know that it does, e.g. for pneumonitis (V20), heart (V5), marrow (V5), hippocampus (V10), and radiosurgery (V12). We know it's harder to repair a high dose region when surrounded by a low dose bath.

Please look over the images and DVH below, and ask yourself honestly: If you needed radiation tomorrow, which one would you choose?

DVH Triangles = VMAT, Squares = Protons.
DVH colors: Sigmoid bowel = magenta, Rectum = brown, Bladder = orange. Red = Prostate PTV (a little dose was added with protons, which may help w/ high risk)

View attachment 306861View attachment 306862
Click to expand...
People tend to forget that the NTCP curve is threshold-sigmoid. If the dose is below the threshold....Oh and don't forget about that dose-range uncertainty...the beam stops but in and individual patient on a specific day exactly where is difficult to know...protons are finicky...RBE...er
DVH idolatry
 
  • Like
Reactions: 1 users
Yes protons are DVH idolatry. But so are all the gymnastics we do to drop mean heart on a breast case by 1-2 gy.

we all want less dose to everything but tumor. IMRT and IGRT and tight margins and pushing your planners are the evolution of this.

proton goes a step further.

when it is cheap, it will make more sense
 
  • Like
Reactions: 1 users
2014XRT said:
Yes protons are DVH idolatry.... when it is cheap, it will make more sense
Click to expand...
Ha... DVH idolatry.

"When [protons are] cheap it will make more sense." Will it??? I would not send a single patient for prostate proton RT right now. First and foremost, protons came on the scene with no randomized clinical data suggesting they could or should supplant the standard of care. Skepticism, versus blanket market acceptance, should have abounded. Second, I have seen too many proton patients first hand that have had weird-to-bad side effects. Third, the published data suggests protons (in prostate) are no better and maybe worse than XRT in terms of side effects.

So if protons were free, would it make sense to send a prostate patient for protons instead of IG-IMRT? Maybe the skepticism I'm talking about re: protons I should have also maintained for IMRT or IGRT. But in those cases after only a few patients I could see tangible clinical benefits over their antecedents. I have friends doing H&N proton RT and they say they see less side effects in their patients with protons. I'm open to protons being a good treatment option, but it's going to take a lot more than just plotting DVH comparisons to compel me to make different treatment decisions as a treating physician. It appears that a DVHxray-to-DVHxray comparison means something different than a DVHxray-to-DVHproton comparison. If protons reimbursed less than XRT there'd be zero patients treated with protons on planet earth today; medical complexes wouldn't be clamoring to install $100+ million proton centers to improve patients' lives, "damn the cost." But I'd use IMRT and IGRT on every patient (but this is based on what I've personally seen) even if they reimbursed less than what they replaced.
 
  • Like
Reactions: 6 users
scarbrtj said:
Ha... DVH idolatry.

"When [protons are] cheap it will make more sense." Will it??? I would not send a single patient for prostate proton RT right now. First and foremost, protons came on the scene with no randomized clinical data suggesting they could or should supplant the standard of care. Skepticism, versus blanket market acceptance, should have abounded. Second, I have seen too many proton patients first hand that have had weird-to-bad side effects. Third, the published data suggests protons (in prostate) are no better and maybe worse than XRT in terms of side effects.
Click to expand...
my exact experience
 
  • Like
Reactions: 1 users
2014XRT said:
Yes protons are DVH idolatry. But so are all the gymnastics we do to drop mean heart on a breast case by 1-2 gy.

we all want less dose to everything but tumor. IMRT and IGRT and tight margins and pushing your planners are the evolution of this.

proton goes a step further.

when it is cheap, it will make more sense
Click to expand...
You should talk to any high volume robotic surgeons in your neck of the woods who do salvage RP for prostate ca. Uniformly the guy I've talked who has done dozens of salvage prostatectomies tells me protons have worst scar tissue/fibrosis and the most difficult cases he has done.
 
  • Like
Reactions: 1 users
medgator said:
You should talk to any high volume robotic surgeons in your neck of the woods who do salvage RP for prostate ca. Uniformly the guy I've talked who has done dozens of salvage prostatectomies tells me protons have worst scar tissue/fibrosis and the most difficult cases he has done.
Click to expand...

I hundred percent agree that many questions exist about the RBE in the high dose region.
 
2014XRT said:
I hundred percent agree that many questions exist about the RBE in the high dose region.
Click to expand...
Which is why i don't think the gi toxicity from protons is something that should be swept under the rug

jamanetwork.com

Intensity-Modulated Radiation Therapy, Proton Therapy, or Conformal Radiation Therapy and Morbidity and Disease Control in Localized Prostate Cancer

In a study of men with prostate cancer who received radiation treatment, Sheets et al used the Surveillance, Epidemiology, and End Results database to examine the comparative morbidity and disease control of intensity-modulated radiation therapy, proton therapy, and conformal radiation therapy.
jamanetwork.com jamanetwork.com

The onus is on the proton folks to disprove that, not anyone else
 
  • Like
Reactions: 1 user
Anecdotally proton centers I know of are using some sort of invasive rectal maneuver- balloon or space oar, yet they still have what appears to be increased late rectal bleeding. Is this other's experience?
 
  • Like
Reactions: 1 user
Protons look great, but the uncertainty of the dose distribution (is the patient getting what the planning system says they are getting) is significant.

Prove an improvement in clinical toxicities and I'll be happy to mention protons as an option to my patients. I'm already mentioning it as an option for esophageal cancer patients given that it's at least being well-studied (eventually).
 
  • Like
Reactions: 1 user
Let me start with a disclaimer I have made a million times before: I am not a billing expert and I am sure there are many intricacies I don't understand.

I was talking with our chief of physics and apparently we were approached by a donor who wanted to invest specifically in a proton unit for our hospital system. This was pre-COVID and he (the chief) was venting about having to finish the pro forma which is clearly an exercise in futility at this point. What I found interesting was using expected treatment codes the estimated billing for a 28 fraction photon IMRT and Proton radiotherapy course for prostate cancer were around $110,000 and $124,000. That differential is no where near what I expected (as in, its not that much).
 
ramsesthenice said:
Let me start with a disclaimer I have made a million times before: I am not a billing expert and I am sure there are many intricacies I don't understand.

I was talking with our chief of physics and apparently we were approached by a donor who wanted to invest specifically in a proton unit for our hospital system. This was pre-COVID and he (the chief) was venting about having to finish the pro forma which is clearly an exercise in futility at this point. What I found interesting was using expected treatment codes the estimated billing for a 28 fraction photon IMRT and Proton radiotherapy course for prostate cancer were around $110,000 and $124,000. That differential is no where near what I expected (as in, its not that much).
Click to expand...
Vs a freestanding center where 44fx is more likely $30-40k. Insane
 
  • Like
Reactions: 2 users
$110,000 for 28 fraction photon IMRT is extremely high. That's why there doesn't seem to be much difference between photons and protons. The photon number is unrealistic, and I wonder if it's simply a mistake or manipulated for multiple possible reasons.

I know what cash patients pay and what some insurances pay for 30 fraction IMRT courses in several centers in my area, and it's on the order of what medgator just posted (and sometimes more like 20-25k).

I've spent time in a few proton centers, and that proton rate is also a bit higher than I'm used to. But it's not as dramatic as the photon rate you posted.
 
  • Like
Reactions: 1 users
Neuronix said:
$110,000 for 28 fraction photon IMRT is extremely high. That's why there doesn't seem to be much difference between photons and protons. The photon number is unrealistic, and I wonder if it's simply a mistake or manipulated for multiple possible reasons.

I know what cash patients pay and what some insurances pay for 30 fraction IMRT courses in several centers in my area, and it's on the order of what medgator just posted (and sometimes more like 20-25k).

I've spent time in a few proton centers, and that proton rate is also a bit higher than I'm used to. But it's not as dramatic as the photon rate you posted.
Click to expand...
Depends on where they are
 
medgator said:
Vs a freestanding center where 44fx is more likely $30-40k. Insane
Click to expand...

Now I feel dirty :(

Your point is taken. The numbers are totally made up. Apparently we end up recouping 30% of the billed total for photons (so somewhere in the 30K range). Seems silly to start with such a high number but as I said, not a billing person. But, I guess in talking with a few other proton centers in our region (using the word region broadly here) they are anticipating a similar billing/payment ratio with protons. At the end of the day they are only expecting to be able to recoup maybe 15% more. Definitely not 2-3x as much.
 
ramsesthenice said:
Let me start with a disclaimer I have made a million times before: I am not a billing expert and I am sure there are many intricacies I don't understand.

I was talking with our chief of physics and apparently we were approached by a donor who wanted to invest specifically in a proton unit for our hospital system. This was pre-COVID and he (the chief) was venting about having to finish the pro forma which is clearly an exercise in futility at this point. What I found interesting was using expected treatment codes the estimated billing for a 28 fraction photon IMRT and Proton radiotherapy course for prostate cancer were around $110,000 and $124,000. That differential is no where near what I expected (as in, its not that much).
Click to expand...
Neuronix said:
$110,000 for 28 fraction photon IMRT is extremely high. That's why there doesn't seem to be much difference between photons and protons. The photon number is unrealistic, and I wonder if it's simply a mistake or manipulated for multiple possible reasons.

I know what cash patients pay and what some insurances pay for 30 fraction IMRT courses in several centers in my area, and it's on the order of what medgator just posted (and sometimes more like 20-25k).

I've spent time in a few proton centers, and that proton rate is also a bit higher than I'm used to. But it's not as dramatic as the photon rate you posted.
Click to expand...
There's what a place bills. And what a place collects. Many may be surprised to know e.g. one can bill Medicare $1 billion dollars per IMRT fraction (well, I think there's only so many spaces for digits on the billing sheet so maybe not 1 with 9 zeroes) and it's not unethical or illegal etc. There's some theory behind "overcharging" (which is not overbilling) that one hopes/prays over time it "reveals" to Medicare what true costs are and stops reimbursement from sinking too much. Most places I have ever worked or heard tell of generally charge 2 to 3 times Medicare rates both to Medicare itself and private insurances. This is "industry standard" AFAIK. And again, you can bill whatever you want. What you'll collect is something altogether different. If you make a pro forma on the basis of pure billing and not collection you may lose your shirt.

EDIT: Under APM Medicare will (possibly) pay ~$23,000 for prostate CA treatment, globally; ~$3,200 to the M.D.
EDIT #2: If Medicare will pay $23K for IG-IMRT, convince me that protons are worth ~$124K.
 
Last edited:
  • Like
Reactions: 2 users
medgator said:
Depends on where they are
Click to expand...

I've worked at two of those centers you linked.

Special rules do apply to them but they aren't THAT special.

The scarb is right about all this I think. Also, they set some high base rates for negotiations with cash payers, funding sources, insurance companies, etc.
 
medgator said:
Depends on where they are
Click to expand...
Neuronix said:
I've worked at two of those centers you linked.

Special rules do apply to them but they aren't THAT special.

The scarb is right about all this I think. Also, they set some high base rates for negotiations with cash payers, funding sources, insurance companies, etc.
Click to expand...
There's some truth in all of this, but I can't tell you which parts are the most truthful lol. There is something special about the link from medgator, and it's probably not that special as you say, but also unmentioned are those shady facility fees that kick in for outpatient hospital based RT which proton centers should have access to... but of course any hospital has access to facility fees be it X-ray or proton tx. What I think (who knows?) is a real kick in the financial pants is if you try and do freestanding protons.
 
  • Like
Reactions: 1 user
scarbrtj said:
There's some truth in all of this, but I can't tell you which parts are the most truthful lol. There is something special about the link from medgator, and it's probably not that special as you say, but also unmentioned are those shady facility fees that kick in for outpatient hospital based RT which proton centers should have access to... but of course any hospital has access to facility fees be it X-ray or proton tx. What I think (who knows?) is a real kick in the financial pants is if you try and do freestanding protons.
Click to expand...

Single or even multiple costly Freestanding oncology anything and you’re already talking a lot less $ and a whole lot more risk.
 
  • Like
Reactions: 1 user
scarbrtj said:
There's what a place bills. And what a place collects. Many may be surprised to know e.g. one can bill Medicare $1 billion dollars per IMRT fraction (well, I think there's only so many spaces for digits on the billing sheet so maybe not 1 with 9 zeroes) and it's not unethical or illegal etc. There's some theory behind "overcharging" (which is not overbilling) that one hopes/prays over time it "reveals" to Medicare what true costs are and stops reimbursement from sinking too much. Most places I have ever worked or heard tell of generally charge 2 to 3 times Medicare rates both to Medicare itself and private insurances. This is "industry standard" AFAIK. And again, you can bill whatever you want. What you'll collect is something altogether different. If you make a pro forma on the basis of pure billing and not collection you may lose your shirt.

EDIT: Under APM Medicare will (possibly) pay ~$23,000 for prostate CA treatment, globally; ~$3,200 to the M.D.
EDIT #2: If Medicare will pay $23K for IG-IMRT, convince me that protons are worth ~$124K.
Click to expand...

So taking care of a head and neck patient pays less than a prostate? According to that link.

Hahahahaha
 
  • Wow
  • Like
Reactions: 1 users
RadsWFA1900 said:
So taking care of a head and neck patient pays less than a prostate? According to that link.

Hahahahaha
Click to expand...

That's the case even now. 30-35 fractions of IMRT gets paid less than 44fx of IMRT with all other things being equal.

We as oncologists know that is obviously not the case, but insurance companies aren't going to magically pay more for a 'difficult' disease site.

I have no idea what my center bills for a 44fx IMRT course, but I do agree that there is a difference between what is billed and what is collected on the hospital level - similar to a hospital's chargemaster (which has caught an awful lot of flak in recent history).
 
  • Like
Reactions: 1 user
Word has it that a proton center in eastern Tennessee is on the ropes. Countdown to closure. The headwinds have been strong. Evicore deciding to cap all prostates at 28 fractions may be playing a role too who knows.
 
  • Haha
Reactions: 1 user
You must log in or register to reply here.
Next unread thread

Similar threads

W
ProPublica Picks Protons
2 3
Replies
135
Views
6K
TheWallnerus
TheWallnerus
D
Waiting for protons ... MDACC edition
Replies
7
Views
940
evilbooyaa
evilbooyaa
Palex80
Photons vs. Protons for Esophageal Cancer
Replies
48
Views
2K
SneakyBooger
SneakyBooger
C
Become a Proton Master in 2.5 days
2
Replies
52
Views
2K
NotMattSpraker
N
I
Proton International center at UAB closing, bankrupt
Replies
34
Views
3K
elementaryschooleconomics
elementaryschooleconomics
Top