An article in Wednesday’s New York Times describes a “new nuclear arms race” in medicine – the proliferation of nuclear particle accelerators for use in radiation therapy for cancer. The article encapsulates a significant challenge we face, in Massachusetts and across the country, in trying to bring the growth of health care costs and spending under control without cutting ourselves off from the medical benefits of new technology.
Proton beams created by particle accelerators are more precise than the x-rays typically used in radiation therapy, according to the article, and are therefore particularly valuable in treating tumors in the eye, brain, neck and spine, and for treating children. Ideally, the health care system would supply enough of this advanced technology to treat all cases where there is a clinical advantage in doing so, but not much more. Unfortunately, there are few mechanisms for ensuring optimal supply. The Times article states that much of the use of the five proton centers operating today is for treating prostate cancer, a use which, according to two radiation oncologists interviewed, is no more effective yet much more expensive than the latest X-ray technology.
The article reports that a dozen more proton therapy centers are being developed, spurred by market forces that include profit-seeking firms and local and state governments promoting medical tourism. Proton centers can cost more than $100 million to build, so it is reasonable to think that, once built, there is tremendous pressure to keep them busy. Medicare pays about $50,000 for proton treatment of prostate cancer, about twice what it pays for radiation therapy using X-rays. In short, proton therapy is, according to a companion article, a potentially very lucrative service. But someone’s lucre is someone else’s cost.
I am singularly unqualified to comment on the medical benefits of proton beam therapy and happily accept the view of experts who see it as a great step forward in the treatment of some cancers. As an informed layperson with a responsibility to consider how to slow the growth of health care spending in Massachusetts, however, I have questions and concerns. My main concern is about the overuse of a “supply-sensitive service,” as described by Dr. Elliot Fisher, to whom I referred in a previous post. To guard against costly oversupply, we must ask: in what cases is this treatment effective, relative to alternatives? What is the cost of the incremental effectiveness? How much investment in new proton therapy capacity is clinically worthwhile? When we have this evidence, how can it best be applied to guide the system toward optimal supply?
The example of the proton accelerators is but one of many that cry out for reasoned analysis in order to allocate resources in the public interest. This is especially critical now in Massachusetts, where the future affordability of coverage expansions depends on the adoption of bold strategies – in the public and private sectors – to bring spending increases under control. The Commonwealth Fund’s Commission on a High Performance Health System recommends as one of its 15 “Options for Achieving Savings and Improving Value in U.S. Health Spending” the creation of a “Center for Medical Effectiveness and Health Care Decision-Making,” which seems to me one logical approach.
Whatever the approach, though, as citizens and representatives of institutions with a stake in the continued availability and affordability of our health care, we must ask these questions and begin to answer them with more rigor than ever before. And we must commit to acting on the answers.
Robert Seifert is a Senior Associate in the Center for Health Law and Economics at UMass Medical School’s Commonwealth Medicine, and is a member of the Massachusetts Health Care Quality and Cost Council.
Those of us that have had external beam radiation as treatment for prostate cancer and who have incurred radiation proctitus or urinary incontinence as a result deplore discussion of cost for a treatment that seems to offer a greatly reduced risk for such unpleasant side effects. We strongly support continued and expanded availability of proton therapy as an option for those who will require treatment in the future. Every man diagnosed with PCa deserves the chance to choose whatever treatment he decides is best for him. Increased availability of proton therapy will inevitably result in lower costs. Certainly we must make medical treatment as economical as possible. Let’s do it by making the system more efficient not by insisting that less than optimum treatments be used simply because they are less costly. My PCa is in clinical remission as a result of external beam radiation administered nearly 11 years ago so that treatment can be considered completely effective. But I can assure you that it would have been more effective in my mind if it had come without side effects.
Cost Effectiveness of Proton Beam Radiation Therapy
Gentlemen and ladies:
I rise to defend protons as an effective treatment for not only prostate cancer, but upwards of forty different forms of this disease.
Protons have been used in a hospital environment in the U. S. since 1991, and more than 44,000 patients have been treated for cancer using protons worldwide. There are five “Centers of Excellence” now using protons in this country, and another three under active construction. There are probably another fifteen in the active planning or design stage There is no way that a hospital or facility would invest the tremendous effort and expense of building these facilities without a very careful cost analysis that weighed all aspects of the long-term results. As the number of facilities continues to increase, the per-patient cost will continue to decrease. When the improvements and reduction in size of the required facilities occur, the expansion of proton facilities will increase accordingly. This is what is really bothering those institutions that do not have the proton capability.
Small wonder that those institutions that lack the foresight to affiliate themselves with a proton facility, if they could not afford the expense of building one themselves, seem to be trying to somehow limit the number of proton facilities in this country. I say to them: “Good luck with that!” The “Genie” is out of the bottle!
Ladies and gentlemen, the REASON that proton beam radiation therapy IS proliferating and will continue to do so, is because it is a non-invasive, minimum side effect treatment with curative results directly comparable to all other modalities, BUT with side effects that are usually minimal to none. There is NO cutting, NO stabbing, NO freezing, No catheters, NO recovery period at all, and minimum radiation burning of organs and tissue (other than the target cancer). There is NO pain, NO nausea, and NO diarrhea. What this means is that there is a distinct advantage for the all important (in my view) “Quality of Life” issues that can affect anyone that has been diagnosed with cancer, and particularly those of us with this thing called prostate cancer.
This is especially important for prostate cancer, for which no one, physicians or patients, can seem to find a distinct and straightforward agreement for any aspect of the disease. Those that have not studied the proton treatment do not realize WHY the modality even exists. It is because of what I call the “elegant physics” of the proton, and the Bragg peak effect, which provides the means of depositing most of the energy of the radiation within the confines of the cancer, then NOT continuing on to cause damage to other tissue and organs.
I challenge any to put a dollar value on the suffering that does indeed occur at times with the other modalities, and could possibly have been avoided with protons. We all know that these things do happen, because we read about them almost daily, if we subscribe to a prostate cancer support forum.
As to costs, Medicare and most insurance companies DO cover the proton treatment. In my case, Medicare and my supplemental covered 100% of my treatment costs. Even in those instances where the cost runs high, the facts support a lower overall cost when one considers the almost complete lack of short-term or long-term side effects that require a doctor’s care, when compared to the other modalities.
And I would point out that protons are the “treatment of choice” among the MAJORITY of radiation oncologists when it comes to the treatment of children with various forms of inoperable cancer. The reasons for this are simple; it is the ONLY radiation that can be used to treat tumors in the midst of the rapidly growing normal cells of a child without causing irreparable damage to the adjacent cells and tissue. Without proton therapy there would be a very great number of children with no option for a cancer treatment that would enable for them a normal life.
I would venture that many reading this, if diagnosed, would travel to a center of excellence for ANY prostate cancer treatment if it were in their means to do so. In my studies of this disease, I found time and again the recommendation to “find the best surgeon (or other specialist) that you can that has done plenty of the procedures.” This involves travel and inconvenience, and yet no one recommends against it. In my case I traveled 2,600 miles for my nine-week proton therapy, and had a great vacation while receiving treatment. In my opinion, we must each study the prostate demon as best we can, and choose the treatment that we find best meets our needs, situation, and the physical characteristics of the disease. This is a choice that is both difficult and personal. The personal opinions of others that may or may not have the same situation or disease characteristics really do not or should not enter into the decision. All that I am advocating is that a newly diagnosed prostate cancer patient should consider proton beam therapy as one of the choices that he has.
Finally, I would again point out that it is the lack of side effects with proton beam therapy that continues to be totally ignored in the negative articles and criticisms that are continually raised by the physicians and institutions that do not have proton capability.
Fuller Jones
Hi I had radiation for rectal cancer in 2005. I have had a lot of problems with the result of radiation and now I think I may have “radiation Proctitus” What are the symptoms and more importantly, the treatment>
Thank you so much
Janet