Happy, sad, good, or bad—it’s all in the words we choose to use. Thanks to Kaiser Health News reporter Jay Hancock’s choices, readers of the New York Times might be led to believe people don’t want proton therapy and that daring to provide it is therefore unwise. His April 27, 2018, unhappy headline declares: For Cancer Centers, Proton Therapy’s Promise Is Undercut by Lagging Demand.
Undercut. Lagging demand. Sounds bleak.
Although the article is not “fake news,” the overall feeling conveyed is one of needless negativity rather than optimism, beginning with the headline itself. Hancock could have used more hopeful terminology but unfortunately chose the opposite. From a professional journalist—a wordsmith by trade—we must regard this as intentional.
The tone of a headline largely determines the reader’s mindset for interpreting what follows. A predisposition for good news or bad can be craftily created by a pro. “Undercut” and “lagging demand” create a mindset of low expectations, and with those words Hancock quickly readies his readers to view any news as bad news.
Even with much the same content, a more upbeat headline would have prepared readers to find the good news in the article. Here are a few examples of similar, but hopeful headlines Hancock could have used, had that been his intent:
Doctors and Insurers Lag Behind Cancer Centers in Promoting Proton’s Promise
Cancer Centers Commit to Proton Therapy Despite Many Challenges
Despite Lagging Support from Doctors and Insurers, Patients Increasingly Demand Proton Therapy
Undaunted by Biased Opposition, Cancer Centers Embrace the Power of Protons
Despite Obstacles, Modern Cancer Centers Beam into the Future with Proton Therapy
With Few Exceptions, Cancer Centers Succeed in Modernizing with High Tech Proton Therapy
Hancock understands the power of a headline. Had he wanted to educate and excite his readers about a promising cancer therapy, he could have done so. He missed an opportunity to encourage naysayers to be more open-minded about an advanced treatment that can help many of us. Instead, he chose to broadcast a warning about the perils of investing in proton therapy—often (he says) doomed to failure.
Jay Hancock wasted a chance to use the power of his pen to help, not impede the advancement of cancer therapy.
And it’s not just his headline. Two seemingly innocuous accompanying photographs visually convey a subtle negativity. One shows an empty gantry and a barren treatment table wrapped in contractor’s tape with a cautionary warning. Another shows an unmanned roomful of unidentified plastic-wrapped equipment roped off with prominent yellow tape in the foreground loudly repeating “CAUTION CAUTION CAUTION CAUTION.”
Hancock missed an opportunity to encourage naysayers to be more open-minded about an advanced treatment that can help many of us.
Why not show a patient in the gantry ready to receive a life-saving proton beam? How hard would it be to find a photograph of a team of technicians actively engaged in managing a cyclotron, the miraculous engine of proton therapy? Again, this choice of imagery can be no accident. Hancock uses it to bolster his headline’s objective.
He hands us a pessimistic headline supported by negative imagery, but that’s not all. There are flaws in the article itself.
Doomsaying without data
In various ways, Hancock repeatedly refers to “the patient shortage” but provides no supporting data, nor does he reference or link to even one data source. He just blithely infers a lack of demand from the fact that some proton centers have closed or had financial difficulty. He completely fails to explore alternate reasons and jumps directly to his biased inference that patients don’t want proton.
In my home state of South Carolina, I can think of several nearby local coffee houses that have closed. Does this indicate a lagging demand for coffee? Maybe, but could it be that those establishments were poorly managed or underfinanced? I do not have a business degree, but I am willing to bet there is a long list of potential reasons a business—any business, even a proton center—might not make it.
Hancock’s gloomy outlook is encapsulated in a single bewildering sentence in which he first tells us that “most of the proton centers in the United States are profitable.” BUT—unwilling to allow a note of optimism to be left standing—he neutralizes the good news by concluding with a contradictory reference to an industry “littered with financial failure.”
His statement is oxymoronic. Success filled with failure? We are left to picture a proton wasteland covered with discarded cyclotrons, reminders of a misguided industry.
A lack of demand is the cornerstone of Hancock’s article, but he never tells us exactly what constitutes a shortage. What number of cancer patients who could benefit from the precision of proton therapy is too few? How many are needed to justify investment in an advanced technology offering “pinpoint precision,” as he correctly describes proton?
Let’s look at some actual numbers with a source we can reference: The National Cancer Institute. For 2018, the NCI projects 1,735,350 new cases of cancer in the United States. Their estimate includes cancers of the breast, lung, bronchus, prostate, colon, rectum, skin, bladder, kidney, pancreas, thyroid, liver, and others. There is clearly no shortage of cancer. Is there a shortage of patients who would want the precision of proton therapy?
There is clearly no shortage of cancer. Is there a shortage of patients who would want the precision of proton therapy?
I could find no numbers indicating how many newly diagnosed patients are estimated to receive which type of treatment, nor how many are unlikely to receive treatment at all. But with nearly two million new cancer patients this year, is it unrealistic to expect 300—a mere 0.01787 percent of the 1,735,350—might want proton therapy near Washington, D.C.? Maybe so, Hancock warns Georgetown University Hospital, where they expect to treat 300 patients annually in their new proton unit.
Demand versus desire
We know there is at least some interest in proton therapy—patients are undeniably being treated with protons every day, worldwide. For the sake of argument, let’s assume the demand is indeed low compared with alternative therapies. Is that a showstopper for the advancement of proton therapy? What might it really indicate?
For starters, it could mean proton therapy is precisely what many cancer patients would want, but either they never heard of it or it’s just too expensive.
I drive a Ford Escape, which transports me with reasonable safety, comfort, and convenience. But I just learned about Rolls Royce’s Cullinan SUV, and I must admit I want one. Sadly, I cannot afford it. I suspect demand—not desire—for the little known, high-priced Cullinan is lower than for my Ford, which I’m sure comes as no surprise to Rolls Royce. Yet even with that awareness, they feel justified in making their SUV.
Proton beam therapy has been referred to as “The Rolls Royce of Radiation Oncology.” Like the Cullinan, it’s not widely known and there are cheaper alternatives—inferior in some circumstances, but not in all. Sometimes a more affordable Ford F-150 or a Honda Accord is a better choice than a luxury SUV. In some cases, IMRT, surgery, or active surveillance may be more appropriate than proton therapy. They all have their place, with differing levels of desire and demand.
Hancock targets “lagging demand” in the headline and therefore should have fully explored this issue. If demand is lagging, we need to understand the reasons. Why aren’t more patients choosing it?
There are three likely reasons people might not buy a Rolls Royce Cullinan. They may not know about it, they might not be able to afford one, or an SUV might not address their needs. The same reasons apply to proton therapy. If doctors “hesitate” to tell patients about it and insurance companies deny coverage to pay for it, then even when proton therapy is the best treatment option, potential demand is stifled.
… demand is stifled because most patients never heard of it, many doctors don’t inform them about it, and insurers often won’t cover it.
Hancock lets his readers assume that demand for proton therapy is lagging simply because patients reject it. More accurately, he should clearly explain that demand is stifled because most patients never heard of it, many doctors don’t inform them about it, and insurers often won’t cover it. The truth is that patients who overcome those obstacles often do choose proton therapy.
Hancock leaves us wondering why more doctors don’t discuss proton therapy with their patients. Nor does he explain why more insurance companies don’t reimburse patients for proton therapy, as they do for other costly major medical expenses. He lets his readers infer that proton radiation must be ill-advised if doctors won’t suggest it and insurers won’t cover it. After all, they’re the experts.
Let’s at least postulate some alternative reasons doctors and insurers aren’t on board. Then maybe we can more intelligently pursue solutions.
Could it be that doctors who “hesitate to prescribe it” have a vested interest in alternative therapies? They might personally perform surgery, IMRT, or another competing treatment, or they might have a financial stake in a facility that does. So maybe they understandably feel threatened by new competition. Or maybe they feel intimidated by a new technology they haven’t investigated. It might feel safer to recommend only what they have done for decades with reasonable success, and not even mention proton. Don’t rock the boat.
When proton therapy is prejudicially excluded, potential demand will be artificially stifled, to the detriment of patients
Insurance companies commonly use three falsehoods as excuses to deny coverage for proton therapy, tragically forcing patients to divert energy from battling cancer to fighting for reimbursement. They deny claims because proton is experimental, not medically necessary, or no better than cheaper choices. I and many others have already discussed these false claims at length. Suffice it to say here that private insurers don’t want to pay the bill for proton therapy and routinely deny coverage because—so far—they can.
We turn to our doctors for objective guidance. We pay for health insurance to provide financial help with major medical costs. When proton therapy is prejudicially excluded, potential demand will be artificially stifled, to the detriment of patients.
A medical arms race
Hancock is apparently wary of the rapid pace at which cancer centers are adding proton capability to their arsenal of cancer-fighting tools. He compares this trend to an arms race, and the extremely negative connotation this carries is again no accident. The public will predictably react subconsciously, if not consciously with a nearly unanimous, “Yikes! We surely don’t want that!”
Ironically, if his analogy were valid and fully understood, it would have the opposite effect. In a military arms race, those in the game do not scramble to accumulate ineffective weaponry. They do not stockpile slingshots and BB guns. They build the most advanced weaponry within their capability. That’s how they win the race.
In the realm of battling cancer, proton therapy is among the most advanced anti-cancer weaponry available, as even Hancock admits. And because there is competition for patients in the business of medicine, cancer centers must consider offering proton therapy. In the United States, 27 facilities now do, and the number is rapidly growing.
Why? Because to succeed, a competitor must offer the best, most up-to-date treatment options available, or risk becoming outdated. Georgetown University Hospital—Hancock’s initial target—added proton therapy to their arsenal for that reason. So did Beaumont Hospital near Detroit, and many others. Good for them.
We may not want to see another military arms race that might lead to an unfortunate war, but a medical arms race to win the war against cancer is exactly what’s needed.
What about profit?
But don’t proton centers need to be profitable? Hancock claims that “nearly a third of the existing centers lose money, have defaulted on debt or have had to overhaul their finances.” He doesn’t say how he arrived at this number, but for the sake of argument let’s assume it is true.
We can concede that making a cancer center fiscally sound is not easy, nor guaranteed. It’s a tough business—probably for any medical facility, not just proton centers. Hancock ignores this possibility and lets readers assume that only proton centers face financial challenges.
One way or another, every business must eventually take in more money than is spent. This includes coffee houses, brick-and-mortar stores, online merchants, and cancer centers. But it doesn’t have to happen overnight, and it’s often worth the wait.
Consider Amazon.com, an innovative, aggressive, trailblazing online merchant. Amazon went public in 1997, lost money for years afterward, and earned very little for even longer. They are now doing more than fine, thanks to their founder’s conviction that investing in future growth is more important than short-term gains and will pay big dividends in the future. It takes time for new ideas to take hold.
If a proton center has a financially rough ride for a while, that’s okay. If they have the means to survive the growing pains, they can ultimately succeed along with the patients they serve. Sure, it would be easier with more support from doctors and insurers, but it’s worth the fight regardless. It’s how medicine advances.
The biggest problem
Dr. Peter Johnstone from Indiana University’s closed proton center has some opinions about running such facilities. Hancock quotes him to support his “lagging demand” premise. Johnstone says, “The biggest problem these guys have is extra capacity.” This brings to mind empty gantries like the one depicted in Hancock’s article.
I disagree with Johnstone. Extra capacity may sometimes be a problem, but it’s not the biggest one. Why would Jacksonville’s University of Florida Health Proton Therapy Institute—a well-established pioneer in this field—invest millions to expand their facility? Empty gantries? Too few patients? Too much capacity? Clearly for them, with patients from all over the world coming there for advanced proton therapy, too little capacity was the bigger concern.
In fact, if the real problems were effectively resolved, I suspect that too much capacity would rarely be a concern. We’ve now discussed at least three such problems I’ll repeat in no particular order. They are (1) lack of insurance coverage for proton therapy, (2) lack of support from doctors who don’t understand proton or have conflicts of interest, and (3) negative bias in the media (ahem).
Eliminate those obstacles, educate the public, and then watch what happens.
The closing statement of Jay Hancock’s editorial-disguised-as-news leaves us in an utterly hopeless place. Alas, proton therapy cannot succeed without “a huge supply of patients.” This is again a quote from Dr. Johnstone, perfect for Hancock’s dismal wrap-up. How huge is huge? Doesn’t matter. “Huge” sounds unattainable, and the implication is that we’ll never get there.
Hancock begins by targeting Georgetown University Hospital as the latest misguided entrant into the so-called medical arms race. I wish he would have ended his article with a quote from Georgetown’s Pam DeLongchamp, one of their nurse navigators. She is excited about proton therapy and its recent advances. She also understands the challenges. When asked by Nurse.com for her words of wisdom for other nurses, she said:
It is an exciting time to be an oncology nurse with new therapies and emerging technologies. Along with this progress comes the ongoing need for continuing education making the time to gain and share knowledge as important as ever. Oncology nurses have many avenues available to obtain this information ranging from online resources to attending meetings and conferences.
This observation applies not only to the many invaluable oncology nurses. It is also good advice for doctors, insurance companies, and Jay Hancock. They should all make time to gain and share knowledge about the latest medical technology—including proton therapy. There’s no excuse. As Pam DeLongchamp said, there are many avenues available.
Just be sure to consider the source and watch out not only for fake news, but for editorials disguised as news.
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