Originally published 9/26/2018
The tug-of-war continues between prostate cancer (PCa) patients who want to be treated with proton beam therapy (PBT) vs. their insurance companies. As you can read from the blog below, payers are denying PCa coverage due to the high cost of the treatment coupled with lack of evidence showing superiority over conventional radiation therapies.
Many doctors see the lack of reimbursement as unfair. “It is truly an injustice to the patient when they would benefit from this treatment but cannot get it,” J. Isabelle Choi, MD, director of research at New York Proton Center.[i] Medical societies would like to see the option of PBT for PCa, but acknowledge that more compelling research evidence is needed to persuade insurers it’s worth the extra cost. The American Society for Radiation Oncology (ASTRO)’s 2017 position paper states: “In order for an informed consensus on the role of PBT for prostate cancer to be reached, it is essential to collect further data, especially to understand how the effectiveness of proton therapy compares to other radiation therapy modalities such as IMRT and brachytherapy.”
Patients can appeal coverage denials, but it takes energy, time, and money. A lot of lawyers are eager to assist in the process—for a price, of course. Determined patients can turn to the courts. In March 2020, two Florida patients (one PCa, one breast cancer) sued AETNA for denying coverage for PBT against their oncologists’ recommendations. In January 2022, “… the judge ruled that the recommendations were ‘prudent and reasonable clinical judgments’ that warranted coverage under medical necessity. The court must now certify the suing class and determine the amount of damages owed to plaintiffs.”[ii] It took nearly two years, with no guarantee of winning, but they did. How much would PBT be worth to you?
At first, proton beam radiation for prostate cancer appeared to be as brilliant a treatment as the pot of gold at the rainbow’s end. I have been following the news on this treatment since I first wrote about it in 2014 when one facility was forced to close its doors. Since then, my blogs have covered the growing reluctance of insurers to cover the cost, the equivalent late-onset side effects as Intensity Modulated Radiation Therapy (IMRT), research showing no proven advantage over other forms of radiation, and a general sense of disappointment after investing huge sums of money just to construct the right kind of facility and equip it with the technology.
What proton beam excels at
Proton beam therapy is different from conventional radiation treatment. Proton beam literally uses protons, which are particles, instead of x-ray beam radiation. Although both types of radiation have the effect of damaging the DNA molecules in cancer cells so they can’t reproduce themselves, protons can be more precisely targeted without the same scatter effect as x-rays.
Proton beam treatment is excellent for conditions such as pediatric brain cancer tumors, liver tumors, lung tumors, gastrointestinal cancers and many types of recurrence. In theory, it was thought to be a better prostate cancer treatment than conventional radiation (including more advanced types such as IMRT and Stereotactic Body Radiation Therapy or SBRT) because less scatter could mean fewer treatment side effects.
The cost of proton beam and the need to treat many patients
Additionally, proton beam is a pricey treatment. It has been called “single most expensive medical device ever built” with facilities costing $20-150 million to build, an investment that is daunting to repay.[iii] Therefore, many patients much be treated. It was only logical to turn to prostate cancer as a source of patients; each year, far more men are diagnosed with prostate cancer than with the other types of cancer I mentioned above.
The trouble is, proton beam is most effective for tumors closer to the surface of the body. Mother Nature placed the prostate in a well-protected position among pelvic organs because of the role it plays in continuing the species. As a recent news story points out, “Little research has shown that proton beam therapy reduces side effects or improves survival for common cancers compared with much cheaper, traditional treatment.”[iv]
Struggling to make ends meet
For the 27 or so proton beam centers in the U.S., making ends meet is an ever-growing challenge. Insurance companies are hesitant to reimburse a high-priced treatment that has yet to demonstrate short- and long-term advantages for prostate cancer. This is not to say that there isn’t a place for proton beam in prostate cancer, and there are still many newly diagnosed patients who rightly view this modality as appealing. However, if patients can’t get reimbursed, the out-of-pocket costs could conceivably range from $30,000 to a staggering $120,000 – in comparison with conventional radiation at roughly $8-10,000, and IMRT at $15,000.[v]
On balance, the evidence points to a huge, perhaps colossal, financial burden for proton beam centers. Perhaps the old saying, “You can’t fight City Hall,” could be modified in this situation: You can’t fight the insurance industry. For proton beam therapy to have a future among prostate cancer patients, there will be an uphill battle for centers to prove its merits to insurance companies.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
[i] Amid questions about cost and access, proton therapy set for ‘big moment of change’.” Healio News. Aug. 25, 2021.
[ii] Moran, Rick. “Cancer patients win lawsuit against AETNA over denied treatment.” Becker’s Payer Issues. Jan. 28, 2022.
[iii] Bryant Furlow. “Cost vs Benefits: The Controversy over Proton Beam Radiotherapy.” Oncology Nurse Advisor, Feb. 28, 2018.
[iv] Jay Hancock. “Proton Centers are Struggling Financially.” Kaiser Health News, May 7, 2018.
[v] Paul Raeburn. “Wise Buy? Proton Beam Therapy.” MedPage Today, May 19, 2017.
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
