Proton Beam Therapy Almost Within Reach for Independent Oncology Practices

David Beyer, MD

The first proton beam therapy units cost huge amounts of money and were well beyond the means of all but the most well-financed cancer centers. However, this technology is vastly cheaper than before, and David Beyer, MD, medical director for Cancer Centers of Northern Arizona Healthcare, foresees a time when proton treatment will become mainstream.

“Now, you can get it into the tens of millions,” Beyer said. “It’s still a big nut to crack. It’s still a challenge for a private practice to spend $30 million. But it’s not as inconceivable as $150 million.” Beyer predicted prices are going to drop further and independent practices will be able to afford this technology. “It’s going to take some time. It’s going to be a few years before the systems get small enough.”

Proton Centers Are Proliferating

Physicians are anxious to see more data emerge, but the utility of this precision form of radiation therapy is undeniable, which means that the cancer center that can offer it will have a competitive advantage. In interviews with Oncology Business Management, oncologists talked about proton beam technology, the ways in which it already has been extended to community level care, and the barriers that remain.When Andrew Lee, MD, guided proton beams toward a patient’s prostate tumor at MD Anderson Proton Therapy Center in May 2006, marking the first time proton therapy was used in Texas, there were fewer than five clinical proton centers in the United States. Ten years later, he oversaw another “first” for proton therapy, this time as the medical director of Texas Center for Proton Therapy. By the time his facility combined pencil beam scanning with isocentric cone beam CT, in April 2016, there were 24 proton therapy centers in the United States and 43 worldwide.

Researchers have pioneered new methods of delivery over the past 10 years. Perhaps the most significant is intensity modulated proton therapy (IMPT), also known as pencil beam therapy, which “paints” proton radiation onto a tumor using individual spots of proton beams, often smaller than a dot made by a pencil. The advent of IMPT in North America in 2008—also delivered for the first time at MD Anderson by Lee—excited clinicians and researchers, who say it increases patients’ quality of life by reducing the side effects caused by excess radiation from traditional radiation therapy. “Anything we can do to eliminate unnecessary radiation is very powerful,” said Steven Frank, MD, medical director of the Proton Therapy Center at MD Anderson.

As excitement about the treatment mounted, more proton therapy centers popped up. Eighteen of the nation’s 24 facilities opened after 2010, and 12 opened in just the past three years, according to the National Association for Proton Therapy.

The research has largely kept pace, said Beyer. A leading publication in the radiation oncology field, the so-called Red Journal—short for the International Journal of Radiation Oncology, Biology and Physics—devoted an edition to proton beam therapy this spring. “The number of proton articles in that journal has gone up because the number of submissions of high-quality proton work has gone up,” Beyer said. “There’s so much, in fact, that they had, in May of this year, an entire edition that was devoted to proton beam—more than 500 pages of just proton articles.”

“And that’s just one journal,” Beyer added.

MD Anderson researchers have authored more than 350 publications on proton beam therapy to date, and the center has only accelerated the pace of its research. “In 10 years, we have advanced and changed an entire industry with new delivery vehicles of proton beam. And we have more to learn,” Frank said. “We don’t know everything about it, and that’s why we have to run these trials.”

As delivery methods grow more sophisticated, proton therapy machines become smaller and cheaper—like IBM computers did, Frank says— although “cheaper” is a relative term when it comes to a multi-million dollar machine. “With the traditional proton facility, you have one cyclotron, and it feeds four treatment rooms. It’s a big, big project, and these big projects are in the hundred-plus million dollar range,” Beyer said. “But there are some people who’ve figured out a way of making this more affordable.”

Companies such as Hitachi, IBA, Mevion, Varian, and ProNova sell those single-room solutions at “a fraction of the cost of a multi-room center of 10 years ago,” Lee said. “When the footprint gets down to probably the $10- to $15-million range, that’s when it’s going to become more universally acceptable and adaptable,” Beyer said.

By contrast, advances in radiation delivery methods have put the cost of a typical radiation treatment machine at around $3 million, Beyer said. Building a state-of-the-art community radiation oncology center today would run up a bill of about $10 million. That’s the cost of the entire facility, Beyer stressed. Not one machine. “Ten million dollars, particularly if you have a group of practicing physicians, is approachable. It can be done,” Beyer said. “You need loans for it—you’re not going to write a check— but you can get loans.”

When a facility costs hundreds of millions of dollars, though, the financing model changes. And securing funds from venture capitalists is often difficult for practicing physicians who want to build a small community facility, Beyer said. “There are some exceptions,” he said. “There was a company that was building centers and partnering with private practices—there’s one in Oklahoma City, for example.”

Frank thinks the partnering model epitomized by the Oklahoma City facility, ProCure Proton Therapy Center, is a more realistic way for community oncology practices to obtain access to IMPT technology. MD Anderson’s proton center accepts patients from the Houston-area cancer centers in the hospital’s regional infrastructure.

“If a patient needs protons, they come over here and get their treatment, but they are still managed in the community,” Frank said. “I envision that that’s probably going to be more of a model that will happen, where you’re going to give more clinicians access so that they can decide when their patients need it and when they don’t. And then it breaks down the concern that they might not have the ability to provide access to various forms of treatment.”

Concern of losing patients to proton beam centers is a valid fear for independent oncology practices, particularly as the research around proton beam therapy grows more authoritative. Ricky Newton, a certified public accountant at Cancer Specialists of Tidewater in Chesapeake, Virginia, put it this way: “Patients see the commercials and the advertisements, and they think this is going to do better than anything else that exists out there, so they get referred over to proton beam, and that pulls them away from private radiation oncologists.”

For all the research being done on proton beam technology, results aren’t yet airtight. The technology has been shown to notably reduce side effects in many cancer sites—the prostate, eyes, head and neck, lung and skull base, among them—and research is being conducted on how well proton beam therapy works on tumors elsewhere in the body.

Organizations such as the American Society for Radiation Oncology (ASTRO), whose board includes Beyer as a member, release model policies to help payers adopt a more uniform policy when it comes to covering proton beam therapy.

Upfront Cost Can Obscure Long-term Value

ASTRO’s most recent policy on proton therapy divides cancer sites into two groups—Group 1, for which there’s “a pretty good agreement that protons have a clear advantage,” and Group 2, for which proton therapy is thought to have a benefit, but it hasn’t been definitively proven, Beyer said. Sites in Group 1 are the eye, the base of the skull, the spine, and pediatric tumors. Sites in Group 2 are “the more common cancers”—malignancies of the head and neck, pelvic region, thoracic region, and abdominal region. Beyer supervised the diverse team of radiation oncologists—from proton skeptics to true believers—who created the ASTRO policy. “We tried to be very careful in how we approached it,” Beyer said. “We found a balance between promoting a new technology that we were very excited about— and I’ll confess we are very excited about the potential for protons—and overexuberance that ignores the fact that we have a responsibility to the greater health system to make sure that our dollars are being spent wisely.”Lee said it’s important to take into account the financial benefits of treating cancer in a manner that reduces or eliminates adverse events. “One needs to consider the overall long-term value of the treatment and not just the actual cost associated with its delivery,” Lee said. “If a treatment like proton therapy can improve cure rates and/or reduce side effects, then it has the potential to be more cost effective over the life of the patient.” Currently, Lee says, proton therapy may provide a significant clinical benefit in roughly 15% to 20% of patients undergoing radiotherapy. It is currently utilized in less than 2% of cases.

Still, the momentum surrounding the treatment shows no sign of letting up. Another proton center will open in the United States in September—in Cincinnati, Ohio—and another 10 are currently under construction or development, according to the National Association for Proton Therapy. Private practices without proton therapy machines can probably sit tight until research grows more widespread, payers warm to the treatment, and systems shrink in size and cost, the interviewed physicians agreed. But at that point community practices may want to reconsider.

“I think private practices are at a little bit of a disadvantage, but that may change as proton becomes more affordable. That may change as we start to develop data that says, ‘You really need it. If you’re treating a lot of prostate cancer, you really need to have a proton machine,’” Beyer said. “If that’s the case, and I happen to have a practice that’s busy treating prostate cancer, I may look at it and say, ‘It’s time to bite the bullet.’”