Modern Healthcare: Despite lack of evidence, more proton beam centers on the way

Providers launch their own trials, registries to prove therapy's effectiveness

Proton-beam therapy centers are proliferating across the country, despite warnings from policy experts and insurers who question whether the costly treatment produces better outcomes for prostate cancer patients, Modern Healthcare's Jaimy Lee reports.

At least a dozen new proton-beam centers, which can cost more than $200 million each to build, are either in development or under construction. Altogether, the new projects will nearly double the total number of facilities operating in the United States. Proponents say that proton-beam therapy offers precision targeting of tumors that spares healthy tissue and reduces side effects associated with other radiation treatments.

However, critics of the therapy have seized on the expense: The procedure can cost more than twice as much as standard radiation, creating a financial incentive that may push hospitals and companies to invest in the facilities and promote proton-beam therapy, even when less costly and equally effective treatments are available for early-stage prostate cancer.

Insurers cite dearth of medical evidence on procedure's superiority

The widespread concern has convinced several major health insurers—including Aetna, Blue Cross and Blue Shield of California, and Cigna—to stop covering proton beam therapy for early-stage prostate cancer, its most frequent use. The insurers cite a dearth of evidence attesting to the treatment's superiority over standard radiation therapy.

WSJ: Proton beam therapy comes 'under attack' from insurers

A study last year found that proton-beam therapy was associated with fewer complications in the first six months after treatment, but that the benefit ceased by 12 months. "The relative reimbursement of new medical technologies needs to be considered carefully so that physicians and hospitals do not have a financial incentive to adopt a technology before supporting evidence is available," the authors wrote.

To date, CMS has not made a national coverage decision for proton-beam therapy. Nonetheless, local Medicare contractors have mostly approved paying for the treatment, which can cost $32,000 for the procedure, compared with $19,000 for more conventional options to treat early-stage prostate cancer.

The willingness of Medicare to pay for the therapy has incented hospitals to build costly proton centers and "run through as many prostate cancer patients as possible to pay off the bonds," Harvard's Amitabh Chandra cautioned last year. Recently, he told Modern Healthcare, "I view proton-beam therapy as ground zero to look at whether we're going to bend the cost curve."

Hospitals gamble on clinical evidence

To address the skepticism over proton-beam therapy, many providers are participating in prospective clinical trials, developing patient registries, and conducting research to prove that the treatment is more beneficial for prostate cancer patients. "Part of the challenge is that there hasn't been a lot of clinical evidence to promote proton therapy," says Stuart Klein of University of Florida (UF) Proton Therapy Institute in Jacksonville. He adds, "As time goes on, the level of clinical evidence is going to increase."

Service Line Strategy Advisor
The New Proton Therapy Marketplace

The institute recently completed a study that analyzed five-year outcomes from three non-randomized trials that followed 211 prostate cancer patients treated with proton-beam therapy. The research concluded that the treatment performed better than other radiation methods used to treat prostate cancer. Additionally, an upcoming clinical trial led by Massachusetts General Hospital will compare proton-beam therapy to IMRT in 700 patients with low- or intermediate-risk prostate cancer.

While the research is underway, some centers say they will continue to treat patients with early-stage prostate cancer. The volume of prostate cancer patients is significantly larger than the number of pediatric or head and neck cancer patients who may benefit from proton therapy, they note. For example, 50% of the nearly 800 patients treated at UF's Proton Therapy Institute have prostate cancer.

However, other centers—like the Mayo Clinic, which plans to open two facilities in the next two years—have opted not to treat low-risk prostate cancer patients. Mayo estimates that up to 15% of its proton patients will be men diagnosed immediate-risk or high-risk prostate cancer.

"We had never planned on treating early stage prostate-cancer patients," says Robert Foote, chair of radiation oncology for Mayo, adding, "A lot of those men don't need any treatment at all." Though he called proton-beam therapy an "exciting new technology," he said its expense justifies the need for a "measured and reasonable approach… [to] find out if it works or not" (Lee, Modern Healthcare, 4/12 [subscription required]).

The Advisory Board's Take

Christopher PericakChris Pericak, Technology Insights

We've seen tremendous proliferation of proton beam therapy, mainly driven by fee-for-service economics and the advent of cheaper single room solutions. Simply put, there's a lower barrier to entry for institutions interested in marketing cutting edge technology as a means to drive volumes. 

At the same time, a series of unfavorable coverage decisions on low-risk prostate cases have all but confirmed the demise of the prostate-based business model. This development—combined with growing market saturation, narrowing networks, and the overall shift towards population health—means that proton providers are going to need to change their strategies. 

Going forward, it will be less and less viable to pursue a trans-regional strategy intended to drive high volumes. Rather, proton providers will need to focus on local or regional markets and coordinate with hospital-based providers to determine the role that protons will play in their network to provide the right treatment for the right patient. They'll also need to conduct clinical trials on non-prostate indications and grow the base of research that would support protons' niche role in improving the quality-to-cost value proposition for certain indications.

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