The Cure: Remaking Health Care ™
Benefits, costs weigh on proton therapy
Proton therapy is a type of radiation used to treat cancer. And it gets at one of the thorniest questions about the health-care overhaul: How do you balance innovation and cost control? Joel Rose reports.
A cyclotron at the Roberts Proton Therapy Center at the University of Pennsylvania (pennmedicine.org)
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CORRECTION: The original version of this story misstated the number of proton therapy centers in the United States. There are seven, with more on the way. The correct number has been inserted in the text below.
TEXT OF STORY
Kai Ryssdal: I know it feels like the health-care discussion has been going on for months. And sure, it has. But today the Senate really got down to it. As debate on the Senate's final bill got started this morning, majority leader Harry Reid said he and his colleagues would be working weekends to wrap things up as quickly as possible.
So far a lot of the attention has been on health insurance, how health care is paid for. Far less work is being done on containing those costs. Costs that continue to rise in part because newer treatments and medicines tend to be pricier than existing ones are. And yet they don't always produce better results.
Today, as part of "The Cure," our ongoing coverage of the health-care overhaul, one of the thorniest questions in the whole debate: How to balance innovation and cost control? Joel Rose went to the University of Pennsylvania to check out a cutting-edge cancer therapy.
JOEL ROSE: In the basement of Penn's new proton therapy center, facility manager Eric Backes shows me a big, round metal object that looks like a small submarine. He nearly has to shout to be heard over the fans keeping it cool.
ERIC Backes: It's basically a 220-ton magnet. The cyclotron spins the protons around and shoots them out through the beam line.
The cyclotron creates a beam that's more precise than other forms of radiation, so doctors can direct it exactly where it's needed.
STEPHEN Hahn: If you're able to give a higher dose of treatment and have less side effects, that's a great win-win situation.
Stephen Hahn is chair of radiation oncology at the University of Pennsylvania. He says conventional radiation can badly damage the healthy tissue around tumors. Hahn hopes proton therapy will help treat cancers where tumors are close to vital organs.
Hahn: The physics of protons are undeniable. If protons were the same price for treating a patient as regular radiation, we would not be having this discussion.
But the price is not the same. Proton therapy centers are expensive: this one cost $140 million. And the treatment typically costs 50 percent more than conventional radiation. That contributes to higher medical bills and indirectly, to higher insurance premiums for the rest of us.
BOB Marckini: I got mine. I received my treatment. And I'm proof positive that it works. That you don't have to give up your sexual function or your urinary function.
This is Bob Marckini -- A.K.A. Proton Bob. He was treated for prostate cancer nine years ago, without any of the nasty side effects that can accompany surgery or radiation. Since then, he's become somewhat of an evangelist for proton therapy. He started a volunteer organization of men who've had the treatment for prostate cancer. It has more than 4,000 members.
Marckini: At any one given day, one of our members, or two or three or four, are standing up in front of a group some place giving a presentation on treatment options, and in particular, proton therapy. That is causing an increase in demand, and that delights me.
That demand hasn't gone unnoticed by hospitals. There are seven proton therapy centers in the U.S., with more on the way. Hospitals see proton therapy as a way to distinguish themselves regionally and nationally by treating cancers others hospitals can't. But these facilities take an enormous investment, and that means pressure to generate income.
Anthony Zietman is an oncologist at Massachusetts General Hospital.
ANTHONY Zietman: The best way to do that is to treat as many patients as you possibly can. So from a business perspective, it makes great sense to treat prostate-cancer patients.
Even if those patients don't need it. Zietman says many prostate cancers are slow growing, and don't require treatment at all. For those that do, Zietman says there's still no clinical evidence that protons are a big improvement over cheaper alternatives.
Zietman: That's the reason why University of Pennsylvania and Mass General are trying to do a randomized trial comparing one treatment with another. At least we'll be able to quantify if proton beam is superior in prostate cancer, and by how much.
The University of Pennsylvania's Stephen Hahn is convinced that proton therapy will prove indispensable for treating certain childhood cancers, and head, neck and lung cancers.
Hahn: If we can define the patients where proton therapy really does benefit them, then I would say as a society we have to come up with the money to do this, because it's the best thing for cancer patients.
Just maybe not all cancer patients. But once you're spent more than $100 million on a proton therapy center, it can be awfully hard to say no.
In Philadelphia, I'm Joel Rose for Marketplace.
Comments
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12/12/2009
Proton therapy should really be widely known to cancer patients throught the United States. Maybe if someone had the decency to make a foundation that makes people donate money to build a cyclotron, then there will be more people getting cured because there will be more hospitals to go to. This new innovation of treating cancer is better than the traditional ways to treat cancer tumors. We really need to work on that in the near future. But sadly, they cost around $160 million, so some people just think that is a little far-fetched, but organizations should be set up so we can donate to make new ones.
It would do so much for the cancerous United States.
12/12/2009
Booty.
From Springhouse, PA, 12/09/2009
To Alan Atsilver - thanks very much for your clarification. How does the resolution of PBT compare with X-ray treatments such as "intensity modulated radiation therapy" (IMRT)? More specifically, what, exactly, is the alleged advantage of PT over other treatments? What does "more precise" mean in the statement "The cyclotron creates a beam that's more precise than other forms of radiation, so doctors can direct it exactly where it's needed."? To Glenn Tonnesen: I would appreciate a detailed explanation or references concerning your statement: "Not one single radiation oncologist in my experience believes that protons will be able to demonstrate a survival advantage, in PROSTATE cancer, over modern intensity-modulated radiation therapy. The details are too complicated to go into, in this brief format, but it�s a fact. The side effects of modern radiation therapy are already minimal. Protons can�t improve on that, either."
12/04/2009
There are in fact 7 US proton centers in operation and UPenn will be the 8th.
Currently operating:
- Loma Linda's James M. Slater, M.D. Proton Treatment and Research Center
- MGH's Francis H. Burr Proton Center
- Midwest Proton Radiotherapy Institute in Bloomington, IN
- MD Anderson's Proton Center
- The University of Florida Proton Therapy Institute, Jacksonville
- The ProCure site in Oklahoma City
AND
- UC Davis proton facility for ocular tumors (only)
From Boston, MA, 12/03/2009
@Mitchell Hirsch
Before you go too far down that path, you should know that proton beam therapy is NOT a focal therapy. The beam is guided to a scattering device that makes some spatial adjustments, but the resolution is very poor. While it is true that you CAN focus proton beams very precisely, the beams used in PBT are NOT focussed very precisely, raster-scanning your particular tumor.
Hitachi has recently gotten FDA approval for their spot-scanning PBT technology, but they are the exception, not the rule.
PBT is not focal therapy. Think about that.
Good luck to you with your PC.
From Springhouse, PA, 12/02/2009
As one who was recently diagnosed with early stage prostate cancer I took a great interest in this story as part of my extensive research on treatment methods and the socio-politics associated with this disease. Having a Ph.D. in physics enables me to assess and compare therapies. One of the statements was that if not for the relative cost there would be no need for discussion - protons win, beyond question. Protons are charged; X-ray photons are not. It follows that protons can be far more precisely focussed.
Spatial precision is essential for minimizing side effects in treating prostate cancer since the spacing between the prostate and other vital tissues - such as nerves which play an essential role in erection - is no more than 2 millimeters. Focal therapies for prostate cancer treatment (also including cryotherapy and focussed ultrasound) have received short shrift, in part because of an old hypothesis (now hardened into a dogma) that prostate cancer is multi-focal (occurring in many locations simultaneously.) There is a growing body of evidence that this hypothesis is false - many instances of prostate cancer - including mine so far - are localized, making focal therapies deserving of widespread serious consideration.
As to th ecost of proton therapy, ttwo comments. First, every treatment was once new and subjected to harsh negative assessments. Second, how are we to put $140 million dollars into perspective? A number by itself is meaningless without a comparison to another number. Takng inflation into account, what was the initial cost of IMRT radiation machines, cyberknife, and the DaVinci surgical robot?
From Mosinee, WI, 12/01/2009
Kai, I was delighted to see your accurate assessment about the health care debate thus far in your second introduction paragraph to this story, namely that most of the attention thus far has been paid to the insurance coverage issues and less work has been done on containing the costs.
As you likely know, 60 minutes recently had (in my opinion) an excellent segment about the costs of end-of-life care in this country. As long as we Americans feel that "gramma should live forever," we need to stop complaining about those costs and merely continue to pay. As long as "defensive medicine" remains alive and well in our litigious society, we need to accept and continue to pay for duplicative and medically unnecessary testing. As long as we remain fascinated by technology (the science of medicine) and place the art of medicine at a distant second place, then we need to accept the fact that costs will continue to increase, because the population base will want to have that technology utilized on them - and so much more is in the pipeline in addition to the proton beam therapy.
Ironically, those listeners who seem to put all their eggs in the prevention "basket," apparently fail to see the resultant increase in the common cancers (breast and prostate) for surely the longer we live, the more likely cancer will be an issue in our lives - not to mention the improving the ability to find cancer at its very early and assymptomatic stages.
1. Let medicine police its own profession, it's time to stop law school graduates from doing it.
2. Accept that gramma is going to die and don't break any bank in trying to prevent this natural end to life.
3. Put the breaks on the development new technology - heck, we don't even know how to best utilize what we already have!
4. Bring back the art of medicine and somehow enhance the status of the Family Doctor, as good basic and preventative care with easy access to that care is currently on a fatal nosedive.
From Columbia, SC, 12/01/2009
Before health reform becomes a reality, there will be twice or three times the number of proton radiation therapy centers to be grandfathered in to the "system." In that same period, 4 years, another 10 million will lose their insurance. Losing health insurance will mean people will forego screening and diagnostic care and treatable cancers will progress to terminal. Wouldn't we be better off as a nation to focus on getting people screened and diagnosed than spreading poorly evaluated wiz-bang expensive technology. When your incentives are based on who profits, the winner is always technology.
From Winter Park, FL, 12/01/2009
UPenn modeled its center after visiting The Proton Therapy Institute (Shands) in Jacksonville FL.(www.floridaproton.com)St Judes is paying for 15 children to go there for brain tumor therapy. CHeck it out. Our 21 yr son was just treated there for inoperable brain tumor near viatl areas. Proton Institue deserves some marketing as the model and mission of all staff is a class act. They have more experience with brain tumors.
Thank you
From Los Angeles, CA, 12/01/2009
Leonard, Thanks for the correction. We've changed the number in the text.
From Falls Church, VA, 12/01/2009
I'm a radiation oncologist, and I welcome some intelligent debate on protons.
Dr. Hahn says that protons are physically more elegant, and that if it weren't for price, there would be no discussion. No argument there! But protons are not, and never will be, as inexpensive as conventional treatment.
The question is not about the radiation particles, but about the outcomes. If protons don’t cure more people, or reduce treatment complications, we can’t afford them.
There is already a small advantage demonstrated for certain childhood cancers. Terrific! Let’s be sure to use protons in these important situations.
Not one single radiation oncologist in my experience believes that protons will be able to demonstrate a survival advantage, in PROSTATE cancer, over modern intensity-modulated radiation therapy. The details are too complicated to go into, in this brief format, but it’s a fact. The side effects of modern radiation therapy are already minimal. Protons can’t improve on that, either.
So why so much talk about protons? Money. There are already enough proton facilities in this country to treat ALL the children who would benefit, but those few patients would never pay for the facilities. All but three of the proton facilities currently operating or under construction were financed by venture capital. How will they pay the investors? Prostates.
Men with prostate cancer are usually old enough to be insured by Medicare, which pays for protons. They are old enough that they are retired and can afford to spend two months away from home for proton treatment. They are not sick or debilitated, and there are lots and lots of them. Prostate facilities are counting on men with prostate cancer to use Medicare (provided with tax money from all of us) to pay for their construction and operating costs – AND provide a profit for their investors.
It’s time to STOP construction of proton facilities until their expense can be justified. Medicare should cover proton treatment ONLY for patients who are being treated on NCI-approved clinical trials.
What about the children? Simple! Declare that Medicare covers selected childhood cancers, exactly the way Medicare covers kidney dialysis. Use Medicare money to transport those unfortunate children and their families to a proton facility and provide them basic housing and support. Give more children the treatment they need (but often can’t afford to get) and save money in the process.
From Chicago, IL, 12/01/2009
This story is actually a very good example of why our system is actually very good. It is innovative and takes care forward, this is not happening everywhere in the world. If you have ever lived overseas and needed care, you will quickly see that our system is not broken. It works quite well. It does need some cost control at the margins and people need to pay more of their own care. By making consumers pay a fixed ratio, with a sufficiently high deductible per service / visit, cost control will come. The most important part of any workable health overhaul is that you have to turn people away that did not buy insurance. This stops the moral hazard and the idea that they can buy the new car or bigger house and skip the insurance.
From menlo park, CA, 11/30/2009
If I, my mom, granddad, etc had a problem, would I want proton therapy for them? Ok. But not to destroy America in the process. All we can do is live healthy, rather than dig the hole we're in any deeper with research like this.
You know what's stressful? Modern America, where health care is better for the privileged. All I'm willing to do is have me and mine eat really well, not be sedentary and live stress free. It's called prevention.
From San Marino, CA, 11/30/2009
I am a physicist who was part of the accelerator team supporting the development of proton therapy at Berkeley (Lawrence Berkeley National Lab). I thought this story was well-balanced and informative but I worried that maybe because of its focus on risk/benefit and prostate cancer the message didn't get across that proton therapy is crucial, a major advance, if a cancer is near an important body organ-- e.g., if it is in the brain or near the spinal cord. My mother was treated because her cancer was in a sinus and with x-ray therapy she would have lost her sight in one eye (tumor near the optical nerve). The problem has been getting doctors to use proton therapy. They get paid every time they send a patient to x-ray therapy. At least when my mother was treated they got nothing for a referral for proton therapy. My mother's doctor as a result did not mention it to her, though he knew about protons, and it is just luck that I knew about the treatment. You were also correct about the universal desirability. If it were cheaper, proton therapy would always be used over x-ray therapy because even though critical body structures aren't necessarily near a tumor, whatever healthy tissue is nearby is hit by x-rays and that limits the dose that can be given. There will be more side effects (from tissue damage) and the treatment is less effective than if (highly-localizable) protons were used because of always having to strike that balance between an effective dose and damage.
From Portland, OR, 11/30/2009
Actually, Kai, the health-care “discussion” in America is decades old. So far vested interests have won because we have government by vested interests. If we had far more preventative health care we would need far less heroic health care like proton machines. But our market system discourages preventative care because it’s not profitable for insurers, hospitals, physicians, employers, pharmaceutical, and medical products companies especially those that make a living selling expensive machinery.
But beyond this America is confronting the limits of Humpty Dumpty health care: the belief that you can abuse your body for decades and when it breaks the health care system will put it together again. No health care system can afford that unless it has infinite resources. A single payer system in which everyone is provided health care (not “coverage”, only insurance companies need that) is economically, medically and morally necessary. But that does not mean we Americans can continue consuming endless calories, junk food with saturated fat, salt and sugar, while scrupulously avoiding sufficient exercise to maintain health. We must take responsibility for our health where we can. Beyond that it’s up to the health care system to do its best for us not for themselves at our expense.
Innovation will not cease in such a system but less of it will be devoted to heroic medical scenarios. The market will have changed from innovation to preserve life at any cost to innovations that help us lead the healthiest most fulfilling lives we can. In a world of limited resources tradeoffs are ineluctable, but a universal single payer system that helps everyone equally will have a different set of tradeoffs and innovations.
From Silver Spring, MD, 11/30/2009
Nice story. Minor correction: There will soon be seven (not six) operating proton therapy centers in the U.S when UPENN begins treating patients quite soon. Patient demand far out weighs our capability to meet their treatment needs. Future growth of proton therapy centers is on the horizon.
National Association for Proton Therapy
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