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When do the superior outcomes from proton therapy justify the costs?

by Lauren Dubinsky, Senior Reporter | July 03, 2024
Rad Oncology Proton Therapy
MD Anderson Cancer Center
Imagine two identical patients. Same age, same medical history, same cancer diagnosis. One of them will be granted access to cutting-edge proton therapy treatment and the other will not. Why? Because their coverage decisions are being made by different insurance companies.

"You could have one insurance product that approves a particular indication for proton therapy, but an identical patient with a different insurance product might not get proton therapy approved," said Dr. Minesh P. Mehta, deputy director and chief of radiation oncology at Miami Cancer Institute. "You can imagine the consternation and confusion that causes, and the time and effort and energy that's wasted in trying to get those approvals."

While many insurance companies are beginning to accept the recommendations of organizations like the American Society for Radiation Oncology (ASTRO) that outline cases where there is a clear benefit to the treatment, other insurance companies — typically smaller ones that lack the bandwidth to keep up with emerging evidence — still do not.

Dr. Minesh P. Mehta
Another reason a payor might refuse to cover proton therapy is because the downstream benefits to the patient for a particular indication, (such as fewer long-term side effects compared to conventional radiotherapy) may not be felt for years to come. "The challenge for an insurance company is that 5, 10, 15 years later, they're not covering that patient," said Mehta. "That patient is somebody else's responsibility, so their perspective is very narrow."

For example, if a woman with breast cancer needs the lymph nodes under her breast bone treated, some of the heart will get irradiated with radiotherapy. That patient's risk of developing cardiac complications later on in life could be diminished with proton therapy, but demonstrating those comparative benefits in a trial study can be difficult.

To address the lack of financial incentive insurance companies have to cover proton therapy, (which is significantly more expensive than conventional radiotherapy), Mehta proposes offering some sort of tax benefit for covering the therapies that result in less long-term toxicity.
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Joern Meissner

solution to the cost-challenge

July 05, 2024 10:21

Dear Editor,
thank you for the nice article pointing out the challenges with proton therapy accessibility and its cost. I wish the article would’ve also focused on solutions, on reducing cost.

Upright patient treatment may be part of the answer. There is currently one FDA cleared proton therapy system that can do upright and supine treatment, is much smaller and hence less costly. There is a second upright treatment system that is about to be FDA cleared. both manufacturers claim that their system fits into linac vault. while this claim needs to be validated through a feasibility study for each installation, it is also easy to see how this is a cost advantage.

attendees of ASTRO, ESTRO and PTCOG know who I’m talking about so I don’t have to mention their names here, and risk that my comment does not get published.

Best regards,
Joern Meissner

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