Proton beam therapy and the medical arms race

Proton beam therapy is an effective modality for killing certain types of cancer cells. New England and the Northeast are fortunate to have a proton beam machine at Massachusetts General Hospital, where it has been in use for some time effectively treating patients. This is a valuable resource, serving the entire region and beyond.

But what happens when everyone wants one? Well, we see the medical arms race at work again.

These are huge and very expensive machines, costing upwards of $150 million dollars. At that price, there should only be a very few in the entire country. Yet, as noted in a recent paper by Anthony Zietman, Michael Goitein, and Joel E. Tepper in the Journal of Clinical Oncology, “In the United States alone, seven centers are in operation and at least 10 more are likely to come into operation in the next decade.”

Proton beam therapy and the medical arms raceHere’s the map of existing facilities and others currently under development or construction, as posted on the web site of the National Association for Proton Therapy (NAPT). What will this look like in a few years?

There is no way this makes sense. As noted, the main value of these machines is in treating certain distinct forms of cancer. The problem occurs when one is purchased as a prestige item. Since there is not enough demand for its use for the appropriate cases, it starts to be used for other types of cancer that would ordinarily be treated with traditional forms of radiotherapy. The article notes:

Protons were used historically to treat relatively rare tumors that were located close to radiation-sensitive normal tissues. Recently, however, much more common cancers are also being treated with protons, notably prostate cancer and non–small-cell lung cancer. The published clinical data on proton therapy have been reviewed in several recent publications. These reviews have underlined the lack of level I evidence for a superiority of proton therapy.

In short, the purchasing hospital needs to figure out a way to amortize the cost, and so it starts using the machine for cancers that were more cost-effectively treated in other ways. The authors explain:

Because of the high capital cost of a proton therapy facility, when a hospital invests in a proton therapy center (or any other expensive new technology), it takes a very substantial financial risk. It has likely elected to reduce its investment in other important areas of health care, it needs to amortize its costs rapidly, and it needs ultimately to generate a profit. Thus, the use of protons becomes as much a business decision as a clinical one; creditors and investors may drive the utilization and potentially the patient mix.

Because of its prevalence, and because of the simplicity and hence economy of its treatments, prostate cancer has become the economic driver for many new proton facilities. Aggressive marketing and high rates of reimbursement mean that the treatment of prostate cancer with protons can be highly profitable. The pressure to undertake such profitable treatments is exacerbated when the success of the business model requires a high throughput of patients.

Who provides the money for these investments? Some is from philanthropists, but the major source is noted in this Forbes article by David Whelan and Robert Langreth: “Most of the $1.5 billion that has been sunk into or committed to building proton centers has come from investors hoping to make a profit. Even the proton center at the august M.D. Anderson Cancer Center in Houston is mostly owned by various investors.”

And it appears that the reimbursement system may aggravate the situation, as Forbes notes: “Medicare pays twice as much for a round of protons as for X-rays: $34,000 for eight weeks of therapy versus $16,000.”

And then elected officials get involved, too:

The centers have become magnets for politics. In Michigan the Beaumont hospital chain struck a deal with ProCure in 2007 and applied to the state for a license. Other hospital systems, including the University of Michigan and Henry Ford, protested, arguing instead for a consortium-run center. State regulators agreed. But Beaumont and ProCure refused to join and lobbied Michigan Governor Jennifer Granholm, who overruled the regulators last year.

President Eisenhower warned us about the military-industrial complex. We are have now entered the era of the health care-finance industry complex.

Paul Levy is the former President and CEO of Beth Israel Deaconess Medical Center in Boston and blogs at Not Running a Hospital. He is the author of Goal Play!: Leadership Lessons from the Soccer Field and How a Blog Held Off the Most Powerful Union in America.

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  • X

    This is exactly the reason why I can’t understand why the public and the federal government still aren’t willing to allow Medicare the ability to use cost as a factor in deciding what it will cover…

  • Discuss Health

    This is one problem of many supposed to be breakthroughs in cancer treatment, the price. It is really difficult to avail cancer treatments that work without spending a fortune. In developing countries, it is very hard to get the optimum cancer treatment, so this proton treatment I guess is not for the masses.

  • Marc Gorayeb, MD

    Simplistic economic analysis. Looking at per-patient charges for treatment of prostate cancer, one should consider the cost of other therapies, such as robot-assisted surgery (total charges may be in the $40,000 to $60,000 range). Treatment of prostate cancer is expensive because effective reduction or elimination of tumor increases the substantial risk of damage to adjacent normal tissues. Proton therapy has not been fully compared to IMRT; that is not unusual in the history of advances in medical technology. On the other hand, compared to surgery, it is certainly less dependent on the skill of your surgeon.
    Granted, the capital investment is enormous, and is likely to require venture-type funding. That’s the American way. But the anticipated returns in the treatment of prostate cancer may mostly come at the expense of other expensive (i.e. surgical) modes of treatment of that disease. The total cost of care for prostate cancer may not necessarily increase out of proportion to the overall benefits derived, as long as urologists don’t start recommending tumor-ablative therapy for those who clearly don’t need it. (That’s an issue that can be separately monitored). What may happen is that fewer patients requiring ablative therapy will suffer the severe complications of surgery.

    • pj

      Dr. Marc, your argument kind of misses the point. The per pt charge isn’t necessarily outrageous, but the unneeded duplication of services is.

      Maybe you disagree w/Paul’s contention that only a few are needed in the USA- but you didn’t say that.

      His beef is, and I don’t see how a reasonable person could disagree, for all the extra- say 15 centers x $150 million or 2.25 BILLION dollars- cost, wouldn’t it be better all around to use that money more productively???

  • Louis Memoli

    A large part of the funding for proton therapy centers comes from venture capitalists. These are not the same people who typically invest in ‘not-for-profit’ ventures. So, if they are going to invest in something, why not proton therapy? These are not discretionary funds that can be applied as WE see fit. Therefore, our focus needs to be on the overall cost of care, including treatment of side effects, readmissions, reoccuring tumors and subsequent treatments, secondary cancers, quality of life, etc. If the outcome data proves that proton therapy is not effective, then it is OUR responsiblity to monitor this in light of other therapies and establish ‘best practice’ guidelines with enforcement through reimbursment incentives. If in the long run proton therapy fails (which I personally doubt), then it is the investors that ultimately lose. I do not wish to see patients treated inappropriately but I do like the idea of outside monies funding expensive medical technologies.

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