Proton beam therapy and the medical arms race

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 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.”

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.

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