Reversing the WSJ Negative Proton Spin

Cutting-Edge Proton Therapy Blasts Into a Bright Future

Falling costs, smaller machines, and private support give insurers fewer excuses

By Ron Nelson
June 8, 2015

Six new treatment centers are expected to begin providing state-of-the-art proton radiation to cancer patients around the country this year. Ten more are anticipated by 2018, bringing the total to 30 centers in the U.S. This explosion of proton centers, each at between $100 million and $200 million to build, indicates growing confidence in the value of this cutting-edge therapy for many types of cancer.

Proton-beam therapy, a highly precise form of radiation, is believed by many to have advantages over traditional photon (x-ray) radiation, but some insurers including UnitedHealth Group Inc. and Aetna Inc. have stopped covering it for prostate cancer, making it difficult for some men to afford this state-of-the-art treatment, regardless of their preference. Nevertheless, proton proponents are undeterred in their quest to make this therapy available to those who need it, and are pursuing new business models despite a lack of support from insurers.

Mevion Medical Systems Inc. is helping the cause. The Littleton, Mass. company makes proton systems with single treatment rooms instead of the four or five offered by larger facilities, and they do this for an investment of only $30 million—possibly even less. Other proton manufacturers, including Ion Beam Applications SA, Hitachi Ltd., and Varian Medical Systems Inc., have also entered the growing market by building their own compact proton systems in the U.S., Europe, Asia and the Mideast.

Regarding the cost of proton therapy, Joseph Jachinowski, chief executive of Mevion, said “there had to be a way to make it more accessible.” Just last month, a Mevion-equipped cancer center in Jacksonville, Fla., became the first proton therapy facility owned by a private physicians group. In addition, five of the six proton centers opening in 2015 are compact centers constructed and operating at only a fraction of the size and cost of larger multi-room facilities.

Officials at many centers say they are using proton radiation not only to treat prostate patients, but also to effectively treat breast, lung and other cancers. To make proton as affordable for patients as traditional photon/x-ray radiation commonly known as IMRT (intensity-modulated radiation therapy), they are experimenting with alternative payment models. For example, The University of Pennsylvania Health System is accepting the same rate for proton therapy that it does for IMRT from two insurers while it tracks patient outcomes. “It’s very important that providers have skin in the game as well as payers,” said radiation oncologist Justin Bekelman.

Private funding has also become part of the evolving proton picture, and some hospitals have turned to private donations, rather than private equity, to finance proton operations. Next month, the Mayo Clinic in Rochester, Minn., plans to start treating patients at its new proton center, one of two built with the help of a $100 million gift. With no investors to repay, they are able to charge the same rates for proton therapy as for IMRT, according to Mayo officials.

“We’re basically telling the insurance companies and our critics—we’re not in this for the money. We think this is the best thing for our patients,” said Sameer Keole, medical director of proton-beam therapy at the Mayo Clinic in Phoenix, scheduled to open next year.

Health systems of all sizes now see proton therapy as not only an attractive option for patients, but also an enticement to obtain top clinicians who are excited about providing cutting-edge care. “All of the top 10 cancer centers in the U.S. have proton therapy or are developing a center, which shows they believe in it,” said Scott Warwick, chair of the National Association for Proton Therapy.

Many radiation oncologists are also enthusiastic about proton technology, in which positively charged particles—protons—are accelerated to about two thirds of the speed of light, and then routed into a powerful beam that deposits most of its radiation energy directly onto the target tumor, minimizing exposure to surrounding healthy tissues. While several treatment options, including proton therapy, can effectively halt cancer, proponents of proton say this phenomenon, called the Bragg peak effect, sharply cuts side effects that can add substantial long-term costs.

There is little disagreement about the benefits of using proton to treat rare pediatric brain cancers, adult eye tumors and cancers at the base of the skull, which insurers generally cover. Some oncologists say proton therapy has a unique ability to reduce harmful side effects in many other localized cancers as well, including head and neck, central-nervous system, lung, prostate and breast, where some patients develop heart damage from spillover radiation provided the traditional non-proton way.

But some insurers are balking at paying for proton therapy for such common cancers without more evidence that it improves patient outcomes. Although there is already much supportive evidence available, these insurers insist they must wait for completion of additional trials now in progress. Because it will be years before those trials are complete, some patients are currently denied this option.

In notable contrast, most Medicare regions do cover proton therapy for prostate cancer. But several major insurers stopped after a 2012 study stated that it has no added long-term benefit. Men with prostate cancer had once accounted for as much as 70% of patients at some proton centers, but this has dropped to less than 50% nationwide, largely because of insurance denials.

At some point, insurers will likely be unable to continue using cost factors to justify denials of coverage. Proton proponents have high hopes that “hypofractionation,” or delivering higher doses of radiation in fewer treatment sessions, will help bring the cost of proton therapy in line with IMRT. Costs will drop even further because smaller proton centers with substantially lower operating costs can more easily remain profitable. Mr. Jachinowski said Mevion’s systems use just 5% of the energy and only 10% of the operating staff of larger facilities—“but the billing codes are the same,” he added.

In the meanwhile, insurance coverage denials have hurt both patients and some proton facilities. Indiana University was unable to compete and closed its facility in Bloomington. In 2013, ProCure Treatment Centers Inc., a private-equity backed operator of proton facilities, sold its share in one center near Chicago after missing a loan payment. Earlier this month, ProTom International Inc., another closely-held builder of compact systems, filed for bankruptcy protection because of a contract dispute over a center in Flint, Michigan.

These examples remind us that despite the promise of proton therapy in fighting many cancers, no facility is guaranteed success. They must each meet the challenges of the marketplace and the ever-evolving insurance industry. They must also fight a continuing public relations battle with critics who remain firm and vocal, calling this therapy pricey and unproven despite evidence to the contrary.

Critics recognize that lower startup costs will lead to a growing number of proton therapy centers, a trend they regard as undesirable because they still view proton as experimental and too expensive . One such critic, Amitabh Chandra, a professor of public policy at Harvard’s Kennedy School of Government, bluntly summarizes, “Now, we’ll have an even bigger problem on our hands.”

Despite the challenges, the promise of proton beam therapy has strong continuing support, and more centers are planned. By 2018, three are expected in the Washington, D.C., area; two in Oklahoma City; two near Dallas; four in Florida; three in New Jersey and one in Manhattan. All expect to become profitable within a few years of opening, and thousands of patients will benefit from easier access to this powerful tool for fighting cancer.

Write to Ron Nelson at .