Proton beam therapy for prostate cancer, a treatment that attracts more than an average numbers of engineers, scientists and pilots, is coming under intense scrutiny from reporters who expect it to be questioned by the Obama adminstration’s health-care reform team.

In an article in today’s New York Times, “In Health Reform, a Cancer Offers an Acid Test,” business writer David Leonhardt compares costs of various treatment options for prostate cancer and says:

. . . . if the treatments have roughly similar benefits, they have very different prices. Watchful waiting costs just a few thousand dollars, in follow-up doctor visits and tests. Surgery to remove the prostate gland costs about $23,000. A targeted form of radiation, known as I.M.R.T., runs $50,000. Proton radiation therapy often exceeds $100,000.

Watchful Waiting, even when it’s snazzed up under today’s term Active Surveillance, really is not a treatment, it’s an approach path to seeing if treatment becomes necessary.

Dr. Daniella Perlroth told Leonhardt that if a relative asked her what to to do about prostate she would advice Watchful Waiting. Guess she knows what she’s talking about, she is an infectious disease physician specializing in “cost-effectiveness of mitigation strategies for pandemic influenza, including social distancing, and anti-viral treatment and prophylaxis strategies.” Leonhardt says she’s also “studied the data.”

Watching the Obama administration cross-consult with swine flu experts and chickenpox specialists to see which prostate cancer treatments to pay for is going to drive us crazy. The big red pencil looming over proton therapy for prostate cancer will drive some men wild.

Leonhardt claims that “The country is paying at least several billion more dollars for prostate treatment than is medically justified — and the bill is rising rapidly.”

Prostate cancer care, he adds, “is one small reason that some companies have stopped offering health insurance. It is also one reason that medical costs are on a pace to make the federal government insolvent.”

Why does he slip in that word “one small reason”? If other reasons are bigger, why isn’t he investigating them?

In any case, from his article today and others over the past couple of years, it’s beginning to look likely that proton beam therapy, with its high initial cost, might be first on the chopping block — unless medical scientists, public input, and maybe some of the lawyers who’ve argued successfully for proton reimbursement on behalf of clients initially denied by their private insurers have an impact.

The attraction of proton beam therapy is that protons, unlike X-rays, are parts of atoms that can pass through healthy tissues with little damage, destroying tumor cells at the end of their path. They do little damage on the way in and they don’t continue out the other side of their target. This is of vital importance in treating prostate cancer because the prostate is situated at a very “busy” part of a man’s body, neighboring his rectum, his bowel, his bladder and his penis.

If radiation is poorly targeted in that region, men can suffer rectal bleeding, persistent diarrhea and loss of bowel control and/or urinary burning, urinary retention and/or urinary incontinence. Some worst case scenarios affected the 92 patients who suffered radiation burns from botched brachytherapy (seeding) at the Philadelphia VA under the care of Dr. Gary Kao.

Even compared with the highly shaped and targeted X-rays produced by IMRT equipment, proton therapy, properly administered, can accurately deliver higher doses of radiation with less damage to surrounding and adjacent tissues. In theory it not only reduces side effects, it saves more lives. Critics, however, say proton therapy is exorbitantly costly and not enough studies of long-term effectiveness are as yet available.

Until recently proton beam therapy required a trip to Loma Linda University Medical Center in Southern California, or to some facility not really patient-ready, more like a science lab than a clinic. For most patients proton therapy also meant a two months’ stay away from home. Now, though, proton facilities are springing up all around the nation at centers like Bloomington, IN and M. D. Anderson, Massachusetts, and Florida. Brand new or under-construction proton facilities include one in Oklahoma and others in Pennsylvania, at Hampton University, VA, and in Northern Illinois and a suburb of Chicago.

Business and biotech writer Andrew Pollack, reporting in the Times in December 2007, evoked a chilling impression of proton therapy invasion, with mini-cyclotrons stalking across the land:

Until 2000, the United States had only one hospital-based proton therapy center. Now there are five, with more than a dozen others announced. Still more are under consideration.

Some experts say there is a vast need for more proton centers. But others contend that an arms race mentality has taken hold, as medical centers try to be first to take advantage of the prestige — and the profits — a proton site could provide.

“I’m fascinated and horrified by the way it’s developing,” said Dr. Anthony L. Zietman, a radiation oncologist at Harvard and Massachusetts General Hospital, which operates a proton center. “This is the dark side of American medicine.”

Once hospitals have made such a huge investment, experts like Dr. Zietman say, doctors will be under pressure to guide patients toward proton therapy when a less costly alternative might suffice.

One little discrepancy stands out here. Pollack interviewed Dr. Jerry D. Slater, the head of radiation medicine at Loma Linda. He and other proponents and practitioners was “adamant that proton centers provide better treatment.”

“It all comes down to the physics,” he said, “Every X-ray beam I use puts most of the dose where I don’t want it.” By contrast, he said, proton beams put most of the dose in the tumor.”

Dr. Zeitmann and others say they are horrified by the cost compared to IMRT. What exactly is the cost for insurers? Zeitmann told Packard: “You can scarcely tell the difference between them except in price. Medicare pays about $50,000 to treat prostate cancer with protons, almost twice as much as with X-rays.”

Wait a minute, that’s not what Leonhardt says in today’s Times. He says, “A targeted form of radiation, known as I.M.R.T., runs $50,000. Proton radiation therapy often exceeds $100,000.”

Which one is correct? If both are correct — one talking about how much Medicare pays and the other about the asking price to the consumer, will this boom in proton facility building pull the cost down?

Can Obama’s healthcare reforms utilize economies of scale, as he has promised overall, and bring the price down further?

Proton beam therapy is fully accepted in some fields — for the brain, and in treatment of children. But as far as its potential for treating prostate cancer is at stake, might this building boom create a proton bubble?

In 2007 a team at Fox-Chase Cancer Center concluded that “Even when based on the unproven assumption that protons will permit a 10-Gy escalation of prostate dose compared with IMRT photons, proton beam therapy is not cost effective for most patients with prostate cancer . . . . Consideration should be given to limiting the number of proton facilities to allow comprehensive evaluation of this modality.”

Three patients who traveled from the Fox-Chase intake area to Loma Linda three years ago had a different outlook. They told the Philadelphia Inquirer in 2006 that they knew men who had had conventional radiotherapy and “they were eager to avoid … impotence and incontinence.”

“Another thing that stood out in my mind,” said Sal Salamone, aged 64, “was that an awful lot of physicians were out there getting treatment.”

LINKS and SOURCES

The Brotherhood of the Balloon

National Association for Proton Therapy
Proton Therapy (wikipedia)
Public Comment for Potential NCD Topics

Fermi Lab Neutron Therapy Facility

Is Proton Beam Therapy Cost Effective in the Treatment of Adenocarcinoma of the Prostate? Andre Konski, William Speier, Alexandra Hanlon, J. Robert Beck, Alan Pollack From the Department of Radiation Oncology, and Population Science Division, Fox Chase Cancer Center, Philadelphia, PA. Journal of Clinical Oncology, Vol 25, No 24 (August 20), 2007.

Hospitals try to land proton beam machine Device’s $200 million cost makes joint effort a necessity. Crain’s New York, June 1, 2009

A Prostate-Cancer Therapy Stirs Debate on Cost, Efficacy Wall Street Journal, September 2008

Proton beam therapy: Is it the future of radiation? HemOnc Today, December 2008.

The $150 Million Zapper David Whelan and Robert Langreth Forbes Magazine dated March 16, 2009

Direct Hit, By Josh Goldstein, Philadephia Inquirer, October 2 2006.