Is it wise to invest in proton beam therapy?
The long-term benefits outweigh the short-term costs
With an increasing number of long-term survivors of all types of childhood cancer, we’re faced with all types of late sequelae either from the cancer itself or the treatment. Some of the major long-term side effects result from the use of conventional radiation therapy, gamma or X-ray beams. It’s particularly problematic in children who are prepubertal or who have continuing growth and development of organs and tissues. Our long-term survivors who were treated with standard radiation for brain tumors, bone and connective tissue tumors and other solid tumors are now having to deal with multiple late effects including secondary malignancies and organ dysfunction.
Proton beam is very exciting because it can target tumors near very critical structures and not cause as much potential damage as normal radiation. If this comes to pass with continued follow-up in children who have had proton beam radiation, in the long run we will save many, many more health care dollars than the initial outlay for the cost of treatment of protons compared to standard radiation. It’s really a long-term benefit that I see, especially in the pediatric population. Also, there is emerging data that some of the acute side effects from radiation such as nausea, vomiting and gastrointestinal toxicity are also lessened by proton therapy, so there is also a potential short-term benefit.
We’re dealing with an entire lifetime in a child who’s cured of cancer. There is good theoretical, and already some actual, evidence there will be significant sparing of normal tissues and structures.
We already have data from the past 30 years telling us that one-third of children who are long-term survivors of cancer have very significant adverse consequences on their health and well-being from prior therapies, especially radiation. If we can minimize those sequelae now, the costs savings should be very, very dramatic. In the long run it will definitely pay off, especially in the pediatric population.
Most of the excitement for proton beam therapy now is in the area of childhood cancer, but there clearly are some adult malignancies such as prostate cancer, brain, eye and spine tumors where you can spare toxicity to surrounding tissues with proton therapy and reduce the complications and therefore the cost of the sequelae of our cancer therapies.
Howard J. Weinstein, MD, is Chief of Pediatric Hematology/Oncology at Massachusetts General Hospital and a HemOnc Today Editorial Board member.
Most patients getting proton beam don’t need it, and overdevelopment will be bad for the entire health care system
No, I don’t think it is wise. I’m really glad there are a few proton centers around the country. There is a need for protons, there are some things that they do that are truly remarkable, and I’m glad that they’re available for those patients.
The problem is there aren’t enough patients who desperately need protons to warrant the number of centers that have been proposed. The proton centers that are being proposed now are largely driven by people who have no history in cancer care, but who have noticed that there happens to be this commodity for which there is a high price and a shortage. That leads investors into the arena.
There aren’t enough patients who need protons, so these proton centers are being largely built for, and largely financed by, people who don’t need them, but might be sold them. That’s not the best thing for our system.
There are some institutions where I think it’s legitimate. I’m not against protons at all. There are enough patients that if you have a few of these centers around the country, you can make good productive use of them. My concern about proton facilities is that somebody smells the chance for big profits and all of a sudden we have too many of them. The day we have too many of them is a bad day for the patient.
Most of the patients who are going to be treated at proton facilities have cancers for which there is no evidence protons are any better. Prostate cancer is a perfect example. There is not a shred of evidence that patients treated with proton beam have a lower recurrence rate or a long-term lower complication rate. There’s no evidence those patients save the health care system money by getting protons. In fact, the evidence suggests they do just as well as patients who have conventional therapies. It’s very hard for me to advocate that patients be treated with something that’s far more expensive just because it’s available and because somebody hopes that it might have better long-term rates. We owe it to our patients and, frankly, we owe it to society to be more skeptical of unproven claims.
The number of patients who can be treated with conventional therapy for the cost of a proton beam facility, $120 million, is staggering. Our national budget for health care isn’t an unending stream of dollars. It’s a zero-sum. There are only so many dollars that the federal government can spend on health care. They can spend it on protons for people who may or may not need it, or they can spend it on a vast array of other health care needs.
We have some significant health care needs in the country right now. We need to find ways of being more economical, not less.
David C. Beyer, MD, is Vice President of Arizona Oncology Services and serves on the Board of Directors for the American Society of Therapeutic Radiology and Oncology. The opinion stated above is his and does not represent the opinion of either organization.