Three essential questions when considering a new proton therapy center

March 13, 2017
By John Jessen

Proton therapy has significantly enhanced and extended our cancer fighting arsenal in the field of radiation oncology. New frontiers in particle therapy include hadron therapy, which relies on beams of charged particles (including protons) and heavier ions (including carbon) to improve cancer cure rates. Advancements in treatment from photon to proton to carbon therapy represent the new way forward in patient care and improving outcomes with far fewer side effects than conventional radiotherapy.

The particle therapy marketplace is projected to reach between $3.5 billion and $6.6 billion by 2030, with 1,200 to 1,800 particle therapy treatment rooms open to patients worldwide, showing an annual growth of 11 percent to 16 percent. However, our research indicates we have far too few proton therapy treatment rooms for current and projected growth. In the U.S., 80 proton therapy treatment rooms are in operation, with projected need estimated at more than 600.

It’s no surprise that many health care organizations are looking to add this highly sophisticated therapy to the radiation matrix. And it is a major decision for any medical center, academic hospital or developer. The time frame for this multi-million dollar investment, from initial planning through first patient treatment, can take five to eight years, or more.

Since working on my first center more than 15 years ago, I have been involved with planning and design of more than 50 proton and particle therapy centers across the globe. Drawing from this experience, I’ve learned that there are three questions that any owner/operator or developer must answer before we can begin to have a meaningful discussion about design, schedule and budget. They include:

• What is your case mix?
• What is your population/catchment area?
• What are your doctors’ preferences?

Simple, but not easy
The first question gets to the heart of the organization mission: Describe your current cancer clinical program. Is it strong or maturing? Is it a niche practice, or a broader treatment spectrum program? What types of tumors will your practice treat: prostate, breast, brain, base of skull, pediatric? And, more precisely, what is the mix of tumor types treated?

Most of the people we meet with are likely already seeing a sizeable number of radiation oncology patients. Indeed, larger centers may see as many as 2,000 to 3,000 cancer patients per year, treating many with conventional X-ray therapy. From this information, we can project the number of potential candidates, already in their care, who could be candidates for proton therapy. Consider that, in 2016, more than 1.6 million people in the U.S. received cancer treatment. And at least 120,000 were good candidates for proton therapy.

Define your patient base
Let’s assume that the clinical program research confirms the need to add proton therapy to the treatment options. Next, we’ll need to know what is the population or catchment area from which you’ll be drawing patients? Here it’s important to know that the population area for proton therapy treatment is not a mirror of current patient volumes. Unlike most medical services, proton therapy centers are still in limited supply. The catchment area may be influenced by existence, or planned existence, of other centers in the region.

The calculation of how many patients per year will be treated in the facility is essential information, and should include a careful study of the organization’s current clinical program (base of potential patients) and information gathered from across the defined geography. The catchment, or population, study should also identify the case mix.

What tumor types — specialization or niche — do the decision-makers envision being treated in the center and what is the breakdown?

For example, 10 percent pediatric, 20 percent prostate, 30 percent brain, etc. Basic answers to these questions will help determine the size and number of treatment rooms required for a specific center being envisioned.

What do the doctors want?
The human factor must also be addressed early in the business planning process. Alongside defining the client/owner’s clinical program and catchment area, the planning and design team must have a clear understanding of how the doctors prepare and treat their patients. There is a misconception that all particle therapy centers are the same and that design and construction default to a cookie-cutter approach. While extremely sophisticated, the PT treatment areas constitute only about 40 percent of the building footprint. The remaining 60 percent of the center is comprised of clinical space. The process and preferences of the center’s physicians are important to document and reflect in the design.

A design team must determine how patients flow most effectively through the space to maximize beam time while accommodating a doctor’s preference. All of this is considered in the context of optimizing the patient experience. For example, do the physicians prefer to pre-position their patients outside of the treatment room? Or within the treatment room? Consider how answers here directly impact the clinic design (more or fewer prepositioning rooms) and number of treatment rooms (positioning within the room impacts the number of people who can be treated).

As medical planners and architects, this information informs even the most basic design decision: the building footprint. With the data above provided, we can derive the volume of patients throughout the day, which, in turn, informs the number of rooms needed to treat the population.

How much space do I need?
Each proton therapy center is unique. Their areas of excellence, their throughput expectations, their case mix — all must be fully vetted. Consider that each tumor type requires patients to spend an average amount of time in the treatment room. Three prostate cancer patients can be treated in one hour, while a child being treated for a brain tumor will require far more time due to the need to sedate the patient, accommodate family and move into a post-treatment recovery room. The tumor type tells us, in general, how many treatments the patient will need over time, and how long they will be in the room for each visit. Although we never lose sight of the fact that these patients are being treated for life-altering illnesses, the formula that drives the decision around the size of the center, and hence, budget, is actually quite simple.

Unlike other types of construction, proton therapy centers are not scalable. Whether the plan calls for one treatment room, or three, the cost per square foot remains relatively constant, and significant, due to the highly specialized nature of the construction, and system, and the equipment installation and commissioning. Over the years, we’ve coached clients through the questions, often working with consultants such as Linda Mischel for feasibility studies, and Leonard Arzt, former executive director of the National Center for Proton Therapy. Each proton center design is finalized through dialogue between the design team and the owner, but the range of sizes appears to be consistent among the many studies we have completed. The surface listed is for the bunker and all clinical spaces:

• One-room proton: 20,000 to 25,000 square feet.
• Two-room proton: 45,000 to 50,000 square feet.
• Three-room proton: 60,000 to 70,000 square feet.

The cost for an average large-size proton therapy center, the size of a football field, can be between $120 million and $200 million, with equipment. These centers typically house four to five treatment rooms, and are able to treat around 1,500 patients a year. A compact one-room proton therapy center, able to treat 200 to 300 patients per year, will cost approximately $30 million, with equipment.

Most of our clients are interested in scaling up over time. In every such case, we recommend building that additional room now and equipping it later. It is far more cost-effective to prepare for additions with the original construction than to add on later. With the essential questions answered and the size of the proton therapy center determined, the rest of the now fully informed design scenario can be developed.

About the author: John Jessen leads the Center of Excellence for Particle Therapy for global design firm Stantec. He is based in the firm’s Washington, D.C. office.