Proton Beam for Prostate Cancer Struggles for Coverage
By: Dan Sperling, MD
Originally published 11/9/2014
The blog below was posted nearly 10 years ago, yet proton beam for prostate cancer (PCa) continues to lack universal coverage.
Reimbursement for proton beam therapy is on the rise for certain cancers, called Group 1 cancers (child and adult cancers in the eye, brain, central nervous system, head and neck, and liver).
A July 2024 news report states that “Medicare patients and pediatric patients who have cancers with a demonstrated benefit from proton therapy typically receive coverage.”
PCa, on the other hand, falls into Group 2 cancers which also includes breast, colorectal, kidney, lung, stomach and other cancers. According to the American Cancer Society, these cancers “should be covered by health insurance providers as long as the patient is enrolled in a clinical trial or patient registry that meets Medicare requirements. These cancers need more study to compare their effectiveness with photon-beam radiotherapy [typical beam therapy for PCa and other cancers].”
In fact, many times even patients with Group 1 cancers are denied coverage despite the fact that clinical studies have demonstrated proton beam effectiveness and less downstream toxicity (side effects) than conventional radiation. Proton beam is considerably more costly than conventional radiation, and relatively few centers offer it.
Until studies with PCa patients demonstrate significant cost-effective benefits over photon radiation, most PCa patients who want it can expect the battle to continue.
For over a decade, using a beam of protons as a weapon against prostate cancer has been viewed as offering great promise. However, proton beam radiation is waging a battle on a new field: the politics of insurance payment.
The economics of proton beam comes down to one word: expensive. In the summer of 2014, the Indiana University Health Proton Center announced that it would close within a year, having sustained losses in the millions of dollars over the 10 years since it opened (see the blog at https://sperlingprostatecenter.com/indiana-proton-beam-facility-closes/). The fact is that constructing and equipping a proton beam center runs up to $200 million. There are currently 14 centers in the U.S., with construction plans for more in the works. These centers depend on payment for the treatments they administer. Scientific data supports coverage of proton therapy for certain cancers that affect the spinal cord, the eye (such as uveal melanoma), and the brain. Because proton beam has less “scatter” than traditional photon beam radiation, it is effective in controlling these cancers while minimizing treatment side effects. In addition to Medicare, private insurance companies such as Blue Cross, Aetna, United Healthcare and Cigna offer coverage for these cancers—but some of them are relatively rare. In other words, the proton beam facilities seek to treat more common cancers.
Prostate cancer is the most prevalent internal cancer among men, with over 230,000 new cases diagnosed annually in the U.S. About a third of patients deemed candidates for whole gland (radical) treatment have some form of radiation. However, the side effects can include eventual sexual dysfunction, bladder or rectal problems, and secondary cancers that show up years later. Patients perceive proton beam as a better radiation choice because it appears to have a lower side effect profile, but insurance companies have yet to find side effect data that is convincing. More importantly, they are rightly concerned with superior cancer control. This is another area in which proton beam has yet to prove itself to major insurers, and it seems to be losing the battle.
Published data on proton beam success as a prostate cancer treatment has not demonstrated significant superiority over other forms of radiation, including Intensity-Modulated Radiation Therapy (IMRT). Yet the Medicare reimbursement rate for prostate cancer therapy is much higher. The reluctance of private insurance to cover the additional cost is understandable, and the refusal to cover proton beam seems to be contagious as one after another private payor is pulling out of coverage.
These policy reversals are creating a true research dilemma. Take the case of University of Pennsylvania’s clinical trial, designed to compare prostate cancer photon vs. proton beam radiation in hopes of demonstrating whether proton beam is truly better on all counts. With a goal of enrolling 400 patients who would be randomized to either proton beam or another treatment, the cost of conducting the treatment and follow-up are daunting. Without payment, the study is unlikely to reach completion any time soon. One other obstacle also affects enrollment: men who want proton beam may refuse to be selected for a comparison arm of the study, simply because they already believe proton is preferable.
The point is, without money, proton beam cannot hope to prove itself worthy of reimbursement; and without proving itself, reimbursement is unlikely to be granted at the level needed to sustain the existing centers as well as those in development.
The search for improved prostate cancer treatments is a complicated one. Today, men with early stage, low-risk cancer are choosing active surveillance in increasing numbers as new genetic evidence suggests that not all prostate cancers will progress into a life-threatening disease. For those patients, however, who are diagnosed with potentially lethal cancers, their available treatment options are inevitably affected by economics, both personal and political. Until matters change, patients will not truly experience freedom of choice.
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.
