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Proton therapy treatment room
(Courtesy of Varian Medical Systems).

Proton therapy did not improve treatment-related toxicity in prostate cancer, study finds

by Nancy Ryerson , Staff Writer
Proton radiotherapy (PRT), an expensive cancer treatment that has received much buzz, did not show any less treatment-related toxicity for prostate cancer patients between 0 and 12 months than less costly intensity-modulated radiotherapy (IMRT), according to a new study published in the Journal of the National Cancer Institute.

The study looked at Medicare beneficiaries age 66 or older who received PRT or IMRT for prostate cancer between 2008 and 2009. Each PRT patient was matched with an IMRT patient with similar clinical and socioeconomic backgrounds. While PRT showed a reduction in genitourinary toxicity in the first six months, when measuring toxicity out to 12 months that difference disappeared.

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"IMRT is the standard of care for prostate cancer, and it already has an outstanding side effect profile," study author James Yu told DOTmed News. "And so we were curious as to whether this more resource intensive and more extensive therapy was better than an already excellent treatment."

According to the study, Median Medicare reimbursement was $32,428 for PRT and $18,575 for IMRT.

Proton therapy has received attention because studies have suggested it causes fewer side effects than traditional radiation. Protons deposit a low dose of radiation when they enter the body, releasing most of it at the end of their path. In theory, that allows oncologists to direct radiation treatment more precisely and reduce damage to tissue surrounding a tumor.

The therapy has been found to improve late side effects in some pediatric brain cancers, but few long-term studies have been performed on other cancers.

"I think the problem with treating the prostate is that you have to add a margin of error because you can't position the patient in the same position every treatment," said Yu. "Also, the rectum is immediately adjacent to the prostate, and the urethra travels right through the prostate, so you can't really avoid those even if you have perfect dosimetry."

There are currently 11 proton therapy centers in the United States. The University of Florida Proton Therapy Institute, which recently installed technology that tracks tumors as they move, responded to Yu's study with data it collected after five years of providing treatment. The Institute says proton therapy resulted in minimal bowel and urinary side effects as well as 99 percent survival in low and intermediate cases, and 74 percent survival in high-risk prostate cancer patients.

Still, Yu as well as organizations such as the National Cancer Institute, Institute of Medicine and the Agency for Healthcare Research and Quality have called for more randomized studies to measure the value of the treatment before more facilities call for it in prostate cancer.

"I think proton therapy is an important part of our treatment as radiation oncologists but the emphasis on prostate cancer treatment may be misplaced," said Yu.

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Misplaced attention on Prostate Cancer
by Wayne Webster on January 02, 2013
I agree with Dr. Yu as to our focus on small improvements with
PRT as compared to IMRT.  Not unlike Neutron therapy of the 1980s
we are focused on a cancer that is already treated reasonably
well with IMRT.  

Protons have some very interesting characteristics and should be
studied and examined carefully.  These centers are not
inexpensive and if we do not try our best to justify their
existence and use at these high reimbursement levels they will be
some of the first big cuts when Obamacare is fully enacted. We
either police ourselves or the Government will do it for us. 
These centers could be easily dealt a death blow with legislation
as far sweeping as the Stark Law.  

Let's face it when you speak with someone planning a PRT center
they speak of the potential improvements in care and in revenue
production almost hand-in-hand.  This is a recipe for disaster in
a time when reimbursement and the quality/effectiveness of the
clinical service will be closely scrutinized by non clinicians
employed by the Government.

Blind Leading the Blind!!
by Dennis Valencia on January 02, 2013
It is a terrible injustice how one group of potentially biased
researchers can publish findings on a therapy that they are not
even proficient at by selecting to focus on a fraction of one
single measurement parameter and then reporting it out like it is
meaningful, or even worse, like it is the ultimate verification
of the efficacy of that modality. Worse than that the potentially
biased media picks up the press-release of study then publishes
it without any further research; while often making up their own
biased head-lines in order to strike another unfair blow against
a modality that they too have a minimal understanding of. If
somebody wants to do a fair comparison of protons versus photons;
they would be best served by bringing out the entire therapeutic
picture, which includes but is not limited to; dose-escalation,
dose-response, control rates, immobilization techniques, control
rates, toxicity and survival. Quality of life measurements should
go beyond a year; reporting on anything less seems highly

Blind Leading the Blind from Dennis Valencia
by Wayne Webster on January 02, 2013
Mr. Valencia,  I think your attack on this one article is
unfortunate.  I believe the facts are quite clear when speaking
to centers about how they make their decisions as to which
imaging modalities, surgical applications and in this case
radiation therapy offerings frequently they decide on early
science and high reimbursement.  

Proton Therapy is interesting but like most new technologies it
really isn't clear that it is much better than anything else.  If
you have statistics to prove Proton Therapy is so much better
that it is worthy of reimbursement that is 2X or more than
standard photon therapy then please publish them please.  

I'm not against Proton Therapy and its installation in the US and
elsewhere.  But when you read the articles that support any new
modality the authors are almost always twisting the statistics to
demonstrate how what they do is better than what is already done.
 I think we have to think about the entire population and
determine if there is enough of an improvement to justify the
cost.  If we don't start thinking this way for ourselves then
maybe the payers will take it upon themselves to do it for us.	

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