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for 20 years after they got standard chemo and radiation often suffer long-term side effects. Almost half (47 percent) of the children suffer from a loss of IQ points, heart toxicity, hearing loss, and the appearance of secondary malignant tumors. In contrast, a longstanding proton therapy site in Switzerland has reported only 7 percent of its patients suffered such long-term side effects from treatment, Laramore says.
That might sound like an intriguing benefit, but it could be misleading for any number of reasons. The gold standard of medical evidence comes from studies in which patients of similar prognosis are randomly assigned to one treatment vs. another and followed over time at multiple clinical sites. The reduced complication rate from Switzerland is the kind of finding that just might persuade a researcher to start such a well-controlled study to ask whether protons are a superior form of treatment for medulloblastoma.
Picking apart one study or another isn’t the real story here. The real problem comes back to the business model, and the financial math required to make this facility pencil out. The Northwest’s new proton center, like many others around the U.S., cost $152 million to build and to operate for its first year, says Annika Andrews, the president of the new center. It has 43 employees, and expects to ramp up to more than 80 at full capacity, Andrews says. When maxed out, the Seattle proton facility should be able to serve 1,400 patients per year, from a five-state regional area, running daily from 7:30 am to 10 pm.
Whenever a private, venture-backed company like ProCure and its lenders pump $152 million into a new facility, you know they have run the numbers on what it will take for this facility to make money. The basic math says it needs a lot of patients, and they each need to pay a lot. While treatment courses vary from tumor type to tumor type, and insurance reimbursement varies by region, proton therapy is typically about 40 percent more expensive than standard treatment, Andrews says. Median Medicare reimbursement for prostate cancer patients on proton therapy is about $32,428, compared with $18,575 per patient for standard radiation, a 75 percent pricing premium, according to a recent article in the Journal of the National Cancer Institute.
Those numbers say a lot about why proton centers are popping up all over the country.
“High reimbursement per case X High throughput X High volume = High profit,” wrote Theodore Lawrence and Mary Feng, a pair of radiation oncologists at the University of Michigan, in the Journal of the National Cancer Institute.
Studies that compare proton therapy and standard radiation for prostate cancer are limited, as it’s historically been difficult to run randomized head-to-head studies with only a few active proton therapy facilities. But one study published last April in the Journal of the American Medical Association said that patients on the standard IMRT (intensity-modulated radiation therapy) had fewer gastrointestinal side effects than patients on proton therapy. Lawrence and Feng note that another study said that 6 percent of prostate cancer patients suffered genitourinary side effects six months after getting proton treatment, compared with 10 percent on standard IMRT. But that apparent advantage disappeared after 12 months.
“Proponents of proton therapy may argue that any reduction in toxicity is worthwhile. However, is this small transient difference enough to justify a 70 percent higher cost per patient?” Lawrence and Feng wrote.
OK, so the evidence on prostate cancer at this point—albeit from a limited data set—says you’ll pay more for proton therapy and not necessarily get more. In fact, you might pay more and get less.