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Is proton beam therapy for prostate cancer worth the cost?

February 20, 2013

By Durado Brooks, MD, MPH


Thousands of men are diagnosed with prostate cancer each month. These men and their loved ones often turn to the internet to learn about their disease and treatment options, and these searches may lead to medical centers offering proton beam therapy.  These centers espouse the benefits of this treatment approach, and some include glowing testimonials from men who have undergone the treatment.

So is proton therapy the "magic bullet" for prostate cancer? 

 

The difference between proton therapy and traditional radiation

Proton therapy is a type of radiation treatment. Traditional radiation therapy has been used to treat cancers for a century using radioactive energy rays called "photons."  When radiation is directed at a cancerous tumor inside the body the rays must pass through normal, healthy tissue in order to reach the cancer cells. In doing so, photons often cause harm to these healthy cells in their quest to get to the tumor. 

In the case of prostate cancer, the radiation beams must pass through the skin, the bladder and the rectum on the way to the prostate gland, and once they reach the gland they encounter normal prostate cells and the nerves that control penile erections.  Damage to these tissues can lead to the complications that often accompany radiation treatment for prostate cancer, including bladder problems, rectal leakage or bleeding, and difficulty with erections.

Proton therapy is a new way to deliver radiation to tumors using tiny, sub-atomic particles (protons) instead of the photons used in conventional radiation treatment. Proton therapy uses new technology to accelerate atoms to 93,000 miles per second, separating the protons from the atom. While moving at this high-speed, the particles are "fired" at the patient's tumor. These charged particles deliver a very high dose of radiation to the cancer but release very little radiation to the normal tissue in their path.  In theory, this approach minimizes damage to healthy organs and structures surrounding the cancer. 

 

Benefits in prostate cancer uncertain


Proton therapy has been proven beneficial for tumors surrounded by sensitive structures such as the eye, brain, and spinal cord, where the potential for radiation damage is very high. Proton therapy also offers a distinct benefit in many childhood cancers due to the high risk of long-term side effects in children who receive standard radiation treatment.

In contrast, most studies of proton therapy for prostate cancer suggest that this new approach may be just as good as standard photon radiation treatment at controlling the growth and spread of the cancer, but there is no evidence that proton treatment does a better job of curing the cancer.

And in spite of the theory that protons cause less damage to normal tissue, there is at present no convincing evidence that urinary (bladder problems), gastrointestinal (rectal leakage or bleeding), or sexual (erectile dysfunction),  complication rates are lower following proton therapy. A few studies suggest that rates of some side effects might even be higher. 

 

Proton therapy popular and profitable


The lack of evidence has not slowed the rapid increase in the use of proton treatment for prostate cancer. One recent study documented a 67% increase in the number of cases of proton treatment for prostate cancer billed to Medicare between 2006 and 2009.  This rate of growth is particularly noteworthy given the limited access to proton therapy: there are at present only 10 proton beam centers operating in the United States, and each center treats only a few hundred cancer patients each year.

 The small number of centers reflects the complexity and cost ($100-$225 million) of building and maintaining the facilities. While equipment needed for standard radiation treatment can usually be added to an existing hospital or treatment facility, delivering proton beam therapy requires constructing a specialized building and installing complicated and expensive equipment to speed up atoms to what's needed to separate the proton and fire it at the tumor.  (Although it should be noted that more prostate cancer patients are being treated with proton therapy because new centers are opening, and increased outreach to patients is resulting in some centers extending hours to treat them.)

With this limited availability and no evidence that proton therapy is better, why is use of the procedure rising at such a feverish pace? Financial incentives may be playing a role. Proton beam therapy for prostate cancer is reimbursed at a much higher rate than traditional radiation treatment for the same condition. Medicare pays about $19,000 for a full dose of standard radiation therapy for prostate cancer, but it pays nearly double for proton therapy - more than $32,000. 

Prostate cancer has become far and away the most common condition for which a Medicare beneficiary receives proton beam therapy, accounting for 2 of every 3 claims and 80% of Medicare spending on the procedure.  So while the cost to build a treatment center is high, proton therapy presents a lucrative opportunity for those who are willing to make the investment.  Established facilities in the US report annual revenue approaching $50 million.  This profit potential is leading to a veritable "arms race" in the field, with the number of facilities in the US expected to double in the next few years.

Given the rising cost of US healthcare it is increasingly important to prove through studies that paying more is associated with better outcomes.  A great deal of research is currently underway to determine whether proton beam therapy for prostate cancer can fulfill the hope of saving livings while limiting side effects and complications.  However, men who are choosing treatment today should be aware that proton therapy's hoped-for benefits have not yet been proven.  Meanwhile these men (as well as Medicare and other insurers) should reasonably ask, "Does it make sense to get the same results yet pay twice as much?"

 

Dr. Brooks is director of prostate and colorectal cancers for the American Cancer Society.

Comments

2/22/2013 9:48:53 AM #

Leonard Arzt

Suggest potential prostate cancer patients review the latest prostate cancer report at the National Association for Proton Therapy web site. The study reports a staggering 99 percent of prostate patients treated with proton therapy believe they made the best treatment decisions for themselves. The report analyzed outcomes and satisfaction of approximately 6,400 patients, some 2,000 completed the survey. What distinguishes this new report is that the data come from patients themselves, reaffirming the results seen from patients for the past two decades. Meaningful data like this have been missing in prior research on proton therapy and helps potential patients made informed decisions.

Leonard Arzt

4/16/2013 6:45:46 PM #

J Yarborough

I finished proton treatment for prostate cancer over a year ago at the UofFL center at the Shands in Jacksonville.  I, and the 30 or so friends made while going through the treatment would do it again.  I don't know for certain of the other 70 or so I met while I was there.  Reading this article has made me question the validity of other articles from the American Cancer Society.  I have provided four recent studies published in the official journal of Nordic oncological societies.
  
Not only do I feel great with no side effects, I didn't have to undergo a hospital stay with surgery and recovery. And although the PSA score is under question, it's what we have to go by and mine is now less that 1/2 of 1%. I am not advocating proton therapy for all. I do strongly recommend each man at least look at proton therapy for themselves, along with other alternatives and make their own mind up.
I would be happy to discuss my experience with any who are attempting to decide on a treatment.


                                              April 2013 UFPTI Published Research
#1
Title: Urinary functional outcomes and toxicity five years after proton therapy for low- and intermediate-risk prostate cancer: Results of two prospective trials

Author/Publication: R. H. Henderson, et al. Acta Oncologica, Apr 2013, Vol. 52, No. 3: 463-469.

Conclusion: Prostate cancer patients treated with proton therapy experience minimal side effects in urinary function after treatment. Moreover, patients who had poor urinary function prior to treatment had significant improvement after treatment.  


#2
Title: Outcomes in men with large prostates (≥ 60 cm3) treated with definitive proton therapy for prostate cancer

Author/Publication: L. Mcgee, et al. Acta Oncologica, Apr 2013, Vol. 52, No. 3: 470-476.   

Conclusion: Proton therapy can be delivered safely to men who have large prostates without hormone (androgen deprivation) therapy. The treatment was associated with low rates of urinary and bowel complications.

#3
Title: Hip fractures and pain following proton therapy for management of prostate cancer

Author/Publication:.  R. Valery, et al.  Acta Oncologica, Apr 2013, Vol. 52, No. 3: 486-491.  

Conclusion: Prostate cancer patients treated with proton therapy did not have increased hip fractures as compared with the expected rates of hip fracture in untreated men.


#4
Title: Hypofractionated passively scattered proton radiotherapy for low- and intermediate-risk prostate cancer is not associated with post-treatment testosterone suppression

Author/Publication:.  W. J. Kil, et al.  Acta Oncologica, Apr 2013, Vol. 52, No. 3: 492-497.  

Conclusion:  Prostate cancer patients treated over a shortened 5.5- week period had no significant change in testosterone level within 12 months post-treatment. When compared with IMRT, the results suggest a more favorable outcome for patients treated with protons.



J Yarborough

5/16/2013 3:27:59 PM #

Mike Hyman

Having met many patients who have gone through proton therapy for prostate cancer I was impressed by their total commitment to the decision to have the treatment. Not one patient had any regret that they chose proton therapy as apposed to invasive surgery or radiation treatment with Photons (x-rays) as we use in the UK.
It is very difficult to ignore the happiness of these patients as they all reported little or no side effects and they all praised the specialists who had treated them.
I suppose there will always be the the knockers who say there is no evidence of the quality of the treatment and if it is better than this or that!!! but innovation has to start somewhere, so surely treatment that offers less side effects has to be respected or does it?
I know which side of the fence I sit on if ever I am unfortunate enough to get prostate cancer!!!
where's the nearest proton machine !!!!

Mike Hyman

6/18/2013 1:23:56 PM #

Deke Rivers

[comment removed per blog comment policy]

Deke Rivers

6/24/2013 4:12:00 PM #

Jamie Kim

I am debating between proton beam therapy vs brachytherapy (seed implant). I know it's really a personal preference when it comes to choosing a right treatment but if anyone has any opinions on brachytherapy vs proton (exterior), I'd appreciate it. Thank You.

Jamie Kim

7/1/2013 9:00:57 PM #

Rob Bigelow

Hi Jamie, I decided to use Proton instead of brachy due to the reviews from other patients. I have T2 so my brachy would call for 5 wks of radiation, hormone treatment, and then seeds. My thought is why have 3 separate treatments when I can do proton in the same amount of time. I have spoken to 3 others who had the proton, one of them 20 yrs ago, One 4 months, and the other three weeks. They all claim satisfaction with their choice. From what I read it just seems to feel right for me. I also have a surgery date but will cancel tomorrow as my insurance accepted this treatment for me which is great news.

Of course any treatment with radiation may cause a problem if the cancer comes back... which makes surgery almost impossible, so I'm told. As you already know they all come with side effects.

I hope this helps, write back if need be!

Rob Bigelow

7/8/2013 1:03:40 PM #

Robert Faulks

The one item that tipped the scale for me to get Proton Radiation was the necessity to have General Anesthesia for other procedures.  No way was I going under.  Too many people I know personally, didn't come out the same as when they went in.  Robert Faulks

Robert Faulks

7/13/2013 10:39:48 AM #

Lee Ballos

To all on this blog,

Could you offer opinion on what Proton Beam center to use for this therapy. I am 58, recently diagnosed with a Gleason score of 6 and my PSA is typically in the low 2's. I live in central Florida and grew up in the Boston area. I know Loma Linda is the most experienced but what about the other centers in the US? Mass General, U Florida Jacksonville, U Pennsylvania etc...

Thanks Gentlemen.

Lee Ballos

7/18/2013 5:54:15 PM #

Mick Wayne

I was diagnosed with intermediate stage prostate cancer four weeks ago.  I have been researching therapies and get the sales pitch of each medical specialty.  The urologist thought that surgery was the best approach.  After having talked to a couple of people who have had both the robotic and the open radical prostatectomy, I realized this is not the way I want to go.  They have more risk in surgery and a higher incidence of incontinence and E.D.  In fact, E.D. seems to be permanent in every one I spoke with.
I then looked at IMRT radiation treatment.  It sounded better than surgery and in many ways is like Proton therapy in that they make a mold for the body, the C.T. tries to focus energy on the prostate only, but it does have a broad beam and there was 30-68 % chance of E.D. and chance of incontinence and rectal/bowel problems.
Proton therapy does have a large number of men who are almost cult like in their devotion to the treatment.  Incontinence is less than 1% and E.D. stands around 30%.  No man wants to see that percentage, but it certainly better odds than surgery or IRMT.
The biggest problem is that there are still only a few centers and the closest one to me is about 300 miles away, meaning that I will literally have to move there for 2 1/2 months for treatment.
I'm still in evaluating phase, but it's hard to find someone to knock Proton therapy except for their competition.  

Mick Wayne

9/19/2013 3:04:09 AM #

Robert Dufala

I was diagnosed with prostate cancer a month ago. My Gleason score was 8, my PSA was 3.7, and of the 12 samples taken during the biopsy, only 1 showed cancer cells.  My MRI and bone scan did not show any issues of concern. Like everyone else, the urologist is recommending surgery.  I am only 60 years old, still work full time for myself, and have been married for 40 years. I would prefer NOT to have a surgery with all of the complications, down time, etc.  Proton therapy sounds like my best option with respect to side effects. I live in SC, so if proton therapy is a good solution for me, I will have to find a place to stay for 3 months wherever I decide to have this done.  And since I have personal insurance, it is unlikely that my insurance will agree to pay for what everyone keeps saying is "experimental" treatment.   So, my question is, how much is this treatment, and how do I find a place to stay?  I am in the process of setting an appt at MDAnderson for the 1 week second opinion process. Is this the best place to go?  Has anyone on this site gone here for treatment? Any help or advice is greatly appreciated.

Robert Dufala

9/28/2013 1:35:35 PM #

Kevin Blair

I am now almost 11 months after completing Proton therapy for my Stage 2 prostate cancer (PSA 6 ... a Gleason 7 or 6 depending on the Pathology reviewer).  I feel good and my  PSA at post 6 months was LT 0.5      Side effects have been two separate 2 to 3week bouts of some bowel urgency, "better get to the toilet quick" ... etc).  These at 2 months post treatment and most recently at 10 months.  Sexually / ED-wise no different ... same as before treatment.   I am 58yrs old and am happy with my choice of Proton therapy.  

I believe in radiation treatment for the my cancer staging.  The most recent x-ray techniques and protons are probably equally effective at zapping the cancer.  I think that Proton will eventually show to be better on the side effects post treatment.   There just need to be the properly structured prospective research studies on outcomes.  If in these studies they can properly measure post treatment costs, quality of life ... etc,  then I predict Proton will show better.  

I was fortunate to live near a Proton center in Chicago area so temp living arrangements were no issue.   I was given the choice to have what they call a hypo-fractionated treatment schedule ... 2 weeks with 5 treatments  rather than  30 treatments over 60 days. It is same total amount of radiation just spread out over less sessions.  Hypo-fraction treatment is newer thinking but its being done also with xray and seems to have started use within last 5yrs.   It is based on research that Protate tissues respond to radiation differently than the surrounding area tissues that you don't wish to damage ... so mostly its a play to reduce post treatment effects.

I'll try to stay up on this blog and put in my comments on some of the prior questions raised.  We'll see where this ride goes next.  

Kevin Blair

Kevin Blair

10/15/2013 10:39:57 PM #

Greg Weir

Robert - I have been going to MD Anderson since I was first diagnosed in 2009 ( I live in Houston). I first got on their watchful/waiting program (Dr Logothitus), until my Gleason on a August biopsy went to 4+3, PSA 9. Then it was recommended that I choose a treatment.  Have spoken with the surgeon (Dr Davis), and also with the radiation oncologist (Dr Mahmood).  I am leaning toward radiation, and most likely the Proton.  They've been doing it there for 8 years I believe.  I've got good insurance now, and am told that it will cover 100% of surgery or Photon radiation.  Still waiting for the insurance feedback on Proton.

Over the past 4 years, I have also see or seen three other Docs at MDA for various other needs.  I am very, very happy with MDA.  First class facility and people for sure. Sometime the waiting room time for an appointment is longer than it should be, but its the exception, rather than the norm.

Greg Weir

10/22/2013 7:21:37 PM #

Stan Shermanton

You mention -->Quote -->A few studies suggest that rates of some side effects might even be higher.

Please identify these studies.

Stan Shermanton

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