Sunday, December 16, 2012

The proton beam chain reaction

The Wall Street Journal had a good article the other day on the issue of proton beam treatment.  The thrust--familiar to my readers--is that these expensive machines have yet to demonstrate clinical efficacy commensurate with their cost:

[P]roton-beam therapy provided no long-term benefit over traditional radiation despite far higher costs, according to a study of 30,000 Medicare beneficiaries published Thursday in the Journal of the National Cancer Institute. 

Yet, as I have mentioned, federal pricing policy is supporting a proliferation of these behemoths, building a cost structure into our health care system that will be a mortgage for years to come.  The Mayo Clinic alone is building two.  The scale:

During the building phase of each project, a total of 500 construction jobs will be created. When fully operational, the two proton beam programs will employ more than 250 new staff members, including 19 physicians and 19 physicists.

Want to build one for your practice or your hospital? Just check out this full-service development company.  Maybe you, too, can get a time-lapse video of your groundbreaking!

If you are a policy geek, here's the scariest part of the WSJ story:

Meantime, researchers at Massachusetts General Hospital and the University of Pennsylvania are enrolling patients in a randomized trial to directly compare proton therapy [for prostate cancer] with IMRT for the first time. "Men need to know which is better, and cancer doctors need to be able to provide the evidence," said Justin Bekelman, a radiation oncology at Penn who is one of the principle investigators.

Think of it, over a billion dollars has now been spent on these machines in the United States; Medicare is paying more for the treatment than for conventional radiotherapy; and we are only now asking the question of whether they offer treatment that is better.  In a rational environment, the study would have taken place using the small number of the first generation machines that were funded with federal support.  Then, if the results were positive, we could have made a rational decision as to how many installations would make sense and where to place them geographically.  But now, the horse is out of the barn.  (Check the locations on this website if you have any doubts--and see this direct-to-consumer advertising as a hint of things that are in place.)

Meanwhile, north of the border, Canadians are debating whether and where to build a full-scale proton beam treatment center.  (My Google search reveals only a small one thus far, for melanoma of the eye, in British Columbia.)  Because of its cost, a large machine would have to be federally authorized; but the organization of health care in Canada is by province, raising the prospect of an interesting competition.  When you consider the size (and thus space needs), technical staffing requirements, and financial condition of the various provincial governments, there are only a few candidate cities.  Toronto would seem a logical spot, for example, but there is not enough space near the major medical center, and the Ontario finances are weak.  Oddly enough (given the small population of the province), Saskatoon might end up as a top candidate.  It has physical space, expert staff, and a surplus in current provincial accounts.

But does Canada need one at all?  The issue appears to have been decided.  As an expert said to me recently, "If we don't build one, there will be a huge outflow of patients to the US for treatment, and we will be forced to pay US prices for something that would be less expensive if we owned it.  Canada cannot afford to export millions of dollars to the States to treat our patients."

The medical arms race has now gone international.  In the words of nuclear arms policy, this is mutually assured destruction.


Anonymous said...

I think we need to be clear (and Paul has been in past posts) that there are cancers for which proton beam radiation is a superior treatment, including, I believe (this is not my area) some pediatric brain tumors. It is the treatment of prostate cancer for which these expensive machines have been hijacked, under the guise of producing fewer side effects which are critical to men - urinary and sexual function. This purported advantage is what the research article debunks.


Anonymous said...

Thanks for the US-Canada experience and how we get drawn into the 'arms race'.

richard.blogger said...

The Department of Health in England approved two proton beam therapy units a year ago. The units will be installed at The Christie in Manchester and UCLH in London. The Outline case is here:

Table 1 (p90) shows that of the expected case mix 1/6 is paediatric, and the remainder are cancers close to the central nervous system. The list does not include prostate cancer.

For completeness, the addendum listing the financial costs are here:

You say that PBT "have yet to demonstrate clinical efficacy commensurate with their cost" and only quote the treatment of prostate cancer.

So my question is this: what about ocular cancer and cancers close to the central nervous system (listed in the DH documents) is there no evidence for the clinical efficacy of PBT for treating those too?

Also, the UK has had a low energy PBT at Clatterbridge for 30 years for treating ocular cancer - has that machine been an expensive mistake too?

Paul Levy said...

I quoted the WSJ article about one study. I imagine there are others that show efficacy with the kinds of cancers you mention. Perhaps other people can cite those. The low energy machines are a different category from the ones being built today in the US.

Anonymous said...

Not much of a consolation, but at least it might be cannibalizing the Da Vinci market...