Tuesday, November 09, 2010

Protons killing cancer and our budget

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 (see graphic below) 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." J Clin Oncol 28:4275-4279

Here'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.

(Graphic is from the Forbes article cited above.)


Anonymous said...

Paul, truer words were never spoken in your last sentence. We saw what happened when the investors' cash went into real estate several years ago; this bubble could dwarf that one.

Then, there is the phenomenon that Americans want to have their cake and eat it too, as evidenced by this Washington Post article yesterday about a prostate cancer vaccine costing $93,000/patient to extend life for 4 months:

"The campaign to win Provenge's approval included anonymous death threats, accusations of conflicts of interest, protests, congressional lobbying and vitriolic Internet postings."

Your comments about indication creep are also well supported by evidence.

We are fiddling (and making money) while Rome burns.


e-Patient Dave said...

This is capitalism run amok - and I say that as someone in business. It seems morally wrong to treat our bodies and our tumors as carcasses to be harvested for the greatest revenue possible. That applies to end-of-life care, cancer care, chronic care, and everything else.

Hardly anyone I know in the patient advocacy world wants unlimited spending - we want the frickin' industry to be more EFFECTIVE, which includes stopping stupid behaviors.

I've started thinking about the need for a cost/benefit grid of treatment options for various things. Is there evidence on efficacy of this machine for prostate cancer vs others?

e-Patient Dave said...

Another view: the opportunity cost of these things seems immense.

(For those who don't know that term, opportunity cost is what else we have to give up in order to do the proposed thing.)

Anonymous said...

Also, a lot of American adults could benefit from the Rose Castorini treatment in "Moonstruck," where she tells her straying husband Cosmo:

"I just want you to know no matter what you do, you're gonna die, just like everybody else."

Unknown said...

Disturbing trend.

I'm encouraged by the fact that this problem doesn't seem to be rooted in the culture of our healthcare infrastructure; rather, it appears to be a straightforward case of improper incentives.

If Medicare reimbursements were limited to the cost of "best alternative effective treatment" until a peer-reviewed panel approved the new approach, I'd suggest that investor support would quickly dwindle and we'd see a more rational number of these uber-expensive capital purchases.

The bad news, of course, is that our healthcare system has a huge number of these incentive issues. Where do we start? In the grand scheme of things, speculative investment in captial equipment is probably one of our smaller issues.

TammyQ said...

Fascinating! As Health Care professionals we like to pride ourselves on our evidence based decisions, but time and time again we see evidence of increasing costs for 'fancy' treatments (equipment, drugs, procedures)that produce no benefit in terms of outcomes. Even in Canada (where hospitals are largely publicly funded) we see this escalating our costs to provide care with no perceivable increase in positive outcomes.

Keith said...

While funded by private investors, it is again an example of how hospitals are the major driver of these new and expensive technologies.

We need health care CEO's who don't make all their decisions on the basis of the bottom line, and who will stop engaging in technological warfare to one up the competition. Unfortunatley, good behavior that has the interest of the commuity at heart seems in short supply. One has to wonder about the unmet primary care neeeds and untreated psychiatric patients we allow to rome the streets while we invest in such costly and largely unproven technology.

I blame a runaway health care system, that rewards its leaders by encouraging them to sell the most expensive treatments with the most significant profit margin, for the uncontrolled costs we have in health care.

Unknown said...

Dr. Levy's opening declaration about proton therapy being an effective modality for treating patients and killing certain types of cancer cells is on the money. Speaking of money, he claims $1.5 billion has been "sunk" (an interesting word to say the least), into building proton centers that he admits is a "valuable resource." I say its money well spent to save lives and provide a far better quality-of-life outcomes for cancer patients compared to his own IMRT machine. Dr. Levy states Medicare pays twice as much for a round of protons vs. X-rays is off the (proton) mark. The Medicare cost for prostate cancer, for example, is $50K for protons and $42 for IMRT, the most commonly used radiation therapy technique.The question is: Which modality is less harmful and best serves his patients? Or, what course of action would he take for himself? I think I know the answer to that one.Not to mention, as he fails to note, the decided advantage proton therapy has for various pediatric cancers. As the NAPT map illustrates, there are only nine operating proton centers in the U.S.Assuming there were 15 treating at full capacity, they would only be able to treat 1-2% of the entire radiotherapy population in the country.That's hardly a blip on the total health care landscape. It is interesting to note Dr. Levy likened President Eisenhower's military-industrial complex warning to a so-called "health care-finance industry complex. Well, it was Eisenhower who created the "Atoms for Peace" program that lead the way toward important medical breakthroughs in nuclear medicine and radiation technologies that we use today --such as proton beam therapy.

Leonard Arzt
National Association for Proton Therapy

Anonymous said...


I am so glad you wrote. Perhaps you will tell us about the NAPT. Who created it? Who are the members and officers? Your Form 990 lists you as Executive Director, but it does not list any other officers.

How is it supported? Your Form 990 lists about $500,000 in income over the past five years. Where does that come from? Is ProCure a contributing member?

76 Degrees in San Diego said...

How do you "hack" these gizmos?

Unknown said...

I am happy to answer personally provide answers to your questions and will call your office
tomorrow. We are a non-profit organization. 990 forms are public information as you have learned.Our members are listed on the web site. Thanks for using our Map and crediting its source.

Len at NAPT

Anonymous said...

e-Patient Dave, it's not capitalism, or at least not the free market flavor of capitalism. The price paid for proton therapy is the result of Medicare's administrative price structure, which is set by non-market mechanisms that completely ignore patient benefit. Hence you get a much higher payment for the majority of proton beam use, without any patient benefit in the vast majority of cases (as compared to non-proton radiation treatments).

Only for specific, rare pediatric cancers are protons demonstrably superior. Therefore, I suggest that only for these specific, rare pediatric cancers should protons have a price one penny higher than equivalently effective non-proton therapies.

Finally, I have to note with some irony the lucidity of Mr. Levy's post on protons...on the same blog that parades BIDMC's surgical robot (no demonstrated better outcomes there, either).

Anonymous said...

I certainly didn't "parade" the surgical robot. Check my post entitled "Uncle!" in which I explained why we ended up buying it.

e-Patient Dave said...

Len, I agree with Paul - thanks for joining the discussion. (He's not a doctor, btw - methinks one major problem in healthcare is that so many organizations are run (and policies set) by doctors, not by people trained in business).

I have some honest questions. Some might sound snarky but I don't intend them that way. I used to help run an industry association (in graphic arts) so I think I can understand a little of your point of view.

I hear you about the value of the treatment and I understand the desire to see it spread as widely as possible. But, obviously, U.S. healthcare is under enormous financial strain, and there's a limit to what we can spend, including on treatments that work. So:

How many $150 million machines do you think are appropriate for the US? Do you feel there's any limit on the reasonable uses of these machines, or do you feel they should rightfully be used on anything where they're effective?

You say 15 machines could treat only 1-2% of radiotherapy patients. Are you suggesting these machines are appropriate for all radiotherapy? If not, how is that number helpful in this discussion?

What do you think about the point that the $150 million cost of one machine could deliver a hell of a lot of care to families in need?

ould NAPT members be willing to donate 10-20% of EBITDA to a fund for indigents? That seems appropriate in light of the laudable value you put on the quality of patients' lives.

Separate point - I don't think saying "he admits" is accurate. It suggests he's contradicting himself when he says the treatment is effective for certain types of cancer cells; do you see anything where he contradicts that?

What he does seem to say is that because they're so expensive, when they're purchased without sufficient rational workload, they get used for treatments *that would not have otherwise justified their purchase*. (Paul will correct me if I'm wrong on that.) He says:

"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."

Paul's "Uncle" post is here. Please read it.

e-Patient Dave said...

Sorry, don't mean to do comment spam, but a friend sent a link to other coverage that throws into question the value of this therapy. I had no idea.

From Journal of the National Cancer Institute:
""A recent report from the Agency for Healthcare Research and Quality (AHRQ) found no evidence to support claims that cancer patients undergoing pricey proton beam radiation therapy (PRT) achieve better outcomes or experience fewer side effects than patients receiving traditional photon radiation. ..."

""It hasn't proven itself to be superior," said Anthony L. Zietman, M.D., professor of radiation oncology at Harvard Medical School in Boston, whose affiliated Massachusetts General Hospital runs one of seven operating proton beam cancer treatment centers in the U.S. "We've applied for a comparative-effectiveness grant to do a head-to-head trial with IMRT with the same radiation dose," he said. The primary endpoint is quality of life.

"Even if funded, it will be years before the results of such a trial are known. ...In the U.S. ...the costly treatment could dramatically increase Medicare spending on prostate cancer care alone."


The article cites the Agency for Healthcare Research & Quality's November 2009 report: "a large number of scientific papers on charged particle radiotherapy for the treatment of cancer currently exist. However, these studies do not document the circumstances in contemporary treatment strategies in which radiotherapy with charged particles is superior to other modalities."

Anyone know if those concerns have been independently addressed in the year since that paper?

Anonymous said...

I live in a town cursed by a proton facility.

The local population is exposed to a constant barrage of misleading direct to consumer advertising.

The often newly diagnosed and desperate health consumer is told that any other treatment is mistreatment!

Of interest a well known marketing firm attests to the power of suggestion on their website. http://www.trsg.net/site/cs-healthcare.php

It's ethically appalling on many levels.

e-Patient Dave said...

Anon 10:15, I looked at the page you linked to, and I don't see reference to the power of suggestion you cite. What are you seeing?

Boy, the wording on that site ("Because of the way the proton is delivered, doctors can inflict greater damage on the tumor, and less damage on the surrounding tissue") seems to disagree with AHRQ and the National Cancer Institute. I wonder if the agency knows that.

Barry Carol said...

Incentives matter. Hospital CEO’s seeking to bolster their institution’s competitive position and improve their share of well reimbursed procedures are competing within the rules of their marketplace. At the same time, employers, finally, are starting to show considerably more interest in value based insurance design beyond tiered drug formularies, which have worked quite well. There is an interesting article in the most recent issue of Health Affairs (subscription required) about applying value based insurance design to high cost procedures such as cancer treatment, major surgeries, advanced imaging and the like. In this instance, value based insurance would either not cover proton beam therapy at all for cancers where it is no better than a less expensive alternative or would at least require patients pay much higher coinsurance if they opt for it.

Anonymous said...


So others don't have to search, here is the text of what the Robin Shepherd Group said about its work:

The University of Florida Proton Therapy Institute is on the leading edge of oncology care. The institute, one of just a handful in the country, uses high-powered protons to deliver bursts of radiation to a tumor. Because of the way the proton is delivered, doctors can inflict greater damage on the tumor, and less damage on the surrounding tissue. A patient can literally receive treatment in the morning and be back on the golf course that afternoon.

We created the brand and website and handled all of the public relations for the institute. We were generating stellar results, including inquiries from as far away as South America. The institute had a waiting list and was successfully treating case after case of prostate, lung, head and neck and pediatric cancers.

In 2009, competing oncology therapies began marketing against proton therapy and inquiries began to slow, particularly when it came to prostate cancer. After examining the marketing mix we were employing versus the competition, we felt the pay-per-click results were not producing at the levels they should be. It was apparent that the media company the client was using to place the PPC numbers couldn't react fast enough to the trends we were seeing. So, we took over the PPC efforts. By streamlining the process, investing in contextual banner ads and refining our site experience to include more relevant landing pages and the use of video, the numbers started trending up almost immediately. Along with the increase in site traffic came an increase in conversions - the result of better targeting with an increased relevance.

Anonymous said...

Barry, unfortunately the difficulty is that most patients with prostate cancer (the apparent marketing focus of this treatment modality) are of Medicare age. So then we enter the sticky wicket of Medicare considering costs when paying for treatment, whether proven or unproven (see my reference above to the Provenge article). It is no wonder the Medicare program is deemed unsustainable in its present form.


e-Patient Dave said...


Yes, I saw that full text of the agency's promo material. I just don't see it as "suggestion" - as someone who's worked in marketing (including web marketing), I just see them strutting their achievement in solving a marketing problem.

That's a separate topic from the efficacy of the treatment. I just see it as touting what they accomplished in response to a decrease in web traffic ("inquiries began to slow").

As you pointed out in your "Uncle" post last year, when customers are leaving (for reasons right or wrong), business managers need to understand the situation and make choices. You decided to buy a da Vinci (in the absence of clinical evidence) simply because patients and residents wanted it; this agency is saying "Web traffic was down due to changes in the environment, and we reversed that trend with our marketing skill."

HOWEVER... rereading that text, I do see one suggestion: "doctors can inflict greater damage on the tumor, and less damage on the surrounding tissue" SUGGESTS "so you'll do better as a patient." I personally agree that it sounds like a solid approach, but I guess the NCI / AHRQ articles say there's not yet evidence on when the extra cost actually produces any benefit.

Anonymous said...

Dear Len,

To your comment: "I am happy to answer personally provide answers to your questions and will call your office tomorrow." Sorry, that doesn't work for this forum. If you have something to say, please say it here for others to see.

If you call me, I'll just transcribe what you say anyway and print it here, so let's skip that step.

Anonymous said...

Where is the list of NAPT members on the NAPT web site?

I am concerned that the public lacks awareness of the diagnostic benefits of MRIs. Is there any way we can get the word out, maybe form a 501(c)(3), so that everyone can be "educated" as to the incredible benefits of this marvelous technology?

Ask your doctor whether an annual MRI is right for you.

Barry Carol said...


I know that the majority of prostate cancer patients getting proton beam treatment are Medicare eligible and I originally intended to submit a paragraph on that subject but deleted it for brevity. I’ll submit it now.

Standard Medicare (excluding Medicare Advantage) is a single payer system for the 65 and over population. So far, it hasn’t shown any interest in value based insurance design including tiered in network co-pays or different coinsurance percentages for different treatments for a given condition based on effectiveness. Its approach consists mainly of dictated prices and (too) rapid payment. Its dictated prices overpay for some procedures crating overuse of those and underpays for others like primary care creating shortages there. It’s policy of paying within 14 days leaves too little time to mitigate fraud which some experts now estimate cost the program as much as $60 billion a year. CMS then touts its low administrative costs as a percentage of total program costs as proof of its efficiency! And this is the program that many on the left want to extend to the entire population. Go figure.

Anonymous said...


I know I am preaching to the choir, but you know what would happen if Medicare tried to introduce those things. Cries of inequitable access and rationing would rapidly ensue. In addition,it is my understanding that Medicare is disallowed by law from considering cost in deciding whether to pay for a treatment - granted, if they do pay, the dictated amounts are often out of whack on a relative basis.

The treatment modality which Paul cites here is a poster child for many, many of the problem issues in our health care system. I do not need to enumerate them for this educated audience, except to say that we have largely brought them upon ourselves, with our outsized expectations and desires to which politicians respond.


Anonymous said...

It may interest you to know that the neighbors at MGH are planning to install a second proton machine.

Anonymous said...

What's missing from both the original post and the comment string is: Where does the money come from to pay for all these gadgets and tests? You and me, our insurance premiums and tax dollars. Some have alluded to it, but let's come right out and say it: the medical arms race makes our premiums go up.

We bash insurers for not controlling costs, and then we bash them again for limiting choices, or making us pay more for those not proven superior. And then hospitals bash insurers for not paying them enough.

There's a lot to hate about the federal reform bill, but any scintilla of supporting evidence-based medicine and comparative effectiveness is not one of them.

e-Patient Dave said...


Paul's "Uncle" post, linked in the original post and a comment, talks about that ... it's been part of the background conversation here for a long time. Apologies for talking insider" instead of adding "As we've said here forever..."

Anonymous said...

Thanks for that note, e-patient Dave. I just discovered this blog and hadn't been exposed to that background. I am very glad this is on people's radar.

Every time I see a sign on a vacant lot that says "Coming soon: your hospital is expanding" I feel like it should say in small print: Your health insurance dollars at work. They could use the same sign on the high-tech equipment.

I work for a health insurer these days, but I've been watching the medical arms race since I was a young reporter in 1979, when hospitals competed for a certificate of need to get a CT scanner, or more beds.

Our spend-thrift culture has infected our attitude about medical treatment just as every other sector of the economy--anytime you pay with OPM (other peoples' money), all bets on economizing are off.