proton therapy, to build up the necessary patient volume. Andrews and Laramore wouldn’t say how many patients they need to treat to reach the break-even point, but Laramore did note that the facility is built for a 30-year lifespan, and “we don’t need to pay it off in the first year.”
Still, there’s no denying you need a lot of patients to pay off such an expensive facility. It creates an incentive for doctors within a network to steer their patients to proton therapy. And there definitely aren’t enough kids in the Northwest with medulloblastoma to keep the place running day and night. All kinds of other cancer patients are being encouraged to consider proton therapy. I have to wonder how many might benefit just as much from an existing, lower-cost alternative.
Protons aren’t for everyone, Laramore acknowledges. People with diffuse tumors, or tumors that are hard to precisely locate, aren’t good candidates. Even so, he says there are plenty of patients who are appropriate candidates. Here in the Northwest, there are about 40,000 cancer patients who get treated in the five-state Washington, Wyoming, Alaska, Montana and Idaho (WWAMI) territory that UW Medicine serves, Laramore says. About 60 percent (27,000 patients) get some form of radiation each year, he says. Even if only 10 percent of those radiation patients get referred to proton therapy, that means the region could support two proton therapy centers, he says. There should be plenty of demand from patients for the new treatment option, and plenty of appropriate patients to refer, Laramore says.
“We feel there is a surplus of demand for the capacity of this particular center, but it’s going to take time,” Andrews says. “It’s a very specialized service. Patient selection is very important.”
Patient selection, I’d agree, is very important. But if you’re going to get 1,400 patients a year, and run them through as many as 40 or so visits for proton therapy, you’re going to have to start referring patients with the really common malignancies—things like prostate cancer and breast cancer. And that is where the medical evidence supporting proton therapy isn’t as compelling. He agrees there isn’t good data from randomized, head-to-head studies that say proton therapy is superior for prostate cancer. When pressed on the data, Laramore kept coming back to the value of protons, as demonstrated in pediatric cancer patients.
Laramore, like I’m sure many physicians would, bristled when I suggested that physicians in the network might be influenced to refer patients to proton therapy for business reasons. He insisted that expert medical judgment, and ultimately the patients themselves, will determine who ends up getting proton therapy.
“Every patient is not a hammer that we’re going to hit with a proton,” Laramore says. (I think he meant to say ‘nail,’ instead of hammer, but you get the idea.)
Still, I have a hard time accepting answers like that, especially when I see such an aggressive media campaign going on to market proton therapy to the masses.
The massive business interest, and the proton marketing campaigns, have invited critics from within the medical community.
Todd Barnett, a radiation oncologist at Swedish Medical Center in Seattle, says he’s personally interested in the potential of proton therapy, and even had a series of business meetings with the ProCure folks when they were considering their Northwest expansion plans five years ago. He says he believes protons offers a proven benefit in certain pediatric cancers. But Swedish backed away from a business deal with ProCure because it believed there weren’t nearly enough pediatric patients to pay for a $150 million facility, and that the high price tag created a perverse economic incentive to direct prostate cancer, and breast cancer patients, to a treatment that may not offer them an advantage.
I spent an hour at Dr. Barnett’s office recently learning about radiation diffusion patterns for standard intensity-modulated radiation therapy, which show great improvement in the ability to precisely target tumors. Laramore agrees that conventional radiation has come a long way, and is much more targeted than it once was. This new kind of standard radiation equipment, made by companies like Elekta and Varian Medical Systems, tends to cost less than $3 million. And unlike proton therapy, these systems have real-time imaging capability that can tell when the tumor has shifted outside the radiation beam, potentially causing harm to healthy tissues.
“There’s no problem that needs a solution here,” Barnett says. “If you have a toaster at home and you want to make toast, you can already do that just fine. If somebody came out with a $9,000 toaster, you’d say, ‘Why would I do that, my toast is fine?’”
I asked another oncologist at Swedish Medical Center, Jack West, what he’d recommend to his dad if he had prostate cancer. Standard IMRT, he says, no doubt.
Both West and Barnett say they are interested in protons, but more curious about the next generation of proton therapy, which may come with real-time imaging capabilities and at a far lower investment in the $25 million to $30 million range. The new technology is in the works at Littleton, MA-based Mevion Medical Systems.
I understand there are people out there who swear by proton therapy, and who say they owe their lives to it. That’s a wonderful thing. Anecdotes make for great stories, and if it’s your life that’s been affected, a pile of medical studies mean nothing but a hill of beans. But that doesn’t mean we can go around buying up every new technology offering that lacks medical evidence.
Andrews, the president of the new ProCure center, acknowledges that medical science can’t yet tell us with a high degree of confidence that protons are superior to standard radiation. If I’m being asked to pay more, I told her, I’d like to know if I’m going to get a documented advantage in survival time, fewer side effects, and an improvement in quality of life.
“These are all good questions,” Andrews says. “Whenever you introduce any new medical technology, there’s a period in which you think about whether this makes sense. Then you come up with new research questions, gather further evidence, and publish it in the literature. That’s the process and the journey we’re undertaking.”
So after thinking about this for a couple weeks, here’s what I think is being proposed. A few businesspeople in our healthcare system have decided to spend massive amounts of money on equipment and marketing, to advance a new treatment paradigm with a mixed bag of medical evidence behind it.
If we really want to know the answer to these research questions, scientists could run a few well-controlled trials at existing proton centers. To my mind, these are the kinds of questions people should know the answers to before investments are made in a dozen proton centers around the country, at $150 million to $200 million a pop. We can’t afford to go on like this forever, blindly worshiping the shiny and new.
