What’s Old Is New Again in Proton Therapy

Proton therapy has always grabbed headlines, captivated us through the use of science and engineering, and sparked discussions among providers, payers and cancer patients about the benefits of such an expensive but marvelous therapy. As the oncology expert at Sg2, I’ve closely followed it. Recent technological advancements and lower-cost solutions make proton therapy relevant in today’s value-based health care market and create the possibility to overtake what, even just a few years ago, was a bleak outlook for its growth.

Three years ago at Executive Summit, Sg2 classified proton therapy as “an avoidable cost.” So what specifically has changed to put proton therapy back on the radar for cancer programs around the country? The answer, like the technology, is complicated. Read on for a discussion of proton therapy’s overall landscape (including recent expansion), the need for additional advancement, and an overview of what to expect if (and when) proton therapy enters your market.

Advances in Proton Therapy Lower Facility Price, Clearing One Hurdle to Wider Adoption
Proton therapy is not new—patients have been receiving proton treatments for over half a century. Last year, the James M Slater, MD, Proton Treatment and Research Center at Loma Linda University, the first hospital-based, multiroom proton treatment facility, celebrated its 25th anniversary, having treated over 17,500 patients with 210 different tumor types. However, building these multiroom proton facilities can cost upwards of $150M. Without evidence demonstrating significant clinical improvement over traditional radiation therapy (ie, photon therapy), proton therapy became the poster child for the excess and waste in health care. Recently, however, this has changed, with major vendors developing compact single-room proton therapy solutions at a fraction of the cost of conventional, multiroom facilities that can be integrated into existing infrastructure.

Vendors with operational single-room proton therapy systems include Mevion Medical Systems (S250), IBA (ProteusONE) and ProTom International (Radiance 330); however, other players are not far behind. The organizations that have installed and commenced operations with these single-room systems include Barnes-Jewish Hospital in St Louis, MO, Robert Wood Johnson University Hospital in New Brunswick, NJ, McLaren Health in Flint, MI, the Ackerman Cancer Center in Jacksonville, FL, and the Willis-Knighton Cancer Center in Shreveport, LA. Look for much more activity to come, as there are multiple sites currently under construction and another vendor (Varian) awaiting FDA clearance for its single-room offering.

In January 2016, there were 20 operational proton facilities across the US with an additional 15 facilities in development or under construction with plans to open in the next 3 to 4 years. This is a big jump from the 11 facilities in operation just 5 years ago. As these new single- and multiroom facilities come online, and as additional single-room systems continue to spring up across the country, I expect to see the cost of the single-room systems come down even further from their current price tag of $25 to $30 million. Proton equipment vendors are finding ways to decrease the operating, equipment and construction costs of these systems. In fact, I recently spoke with one of the newer vendors in the market who hoped to be able to sell their 2-room facility for $10 million per room within the next 2 to 3 years.

Proton Therapy Faces Adoption Barriers Beyond Facility Costs
If the exorbitant cost of proton therapy goes away, what’s keeping everyone from presenting a plan for a proton facility to their technology acquisition committees? There are still a few significant hurdles to clear regarding proton therapy’s clinical evidence base, reimbursement rates and lagging technology advancements compared to other modalities.

More Clinical Evidence Is Needed
The clinical evidence in support of proton therapy needs to expand. With the exception of pediatric cancers, ocular tumors and brain/spine tumors, where the clinical evidence and use of proton therapy is justified, there is little evidence showing proton therapy provides significant clinical improvement over current radiation therapy. Now, you can certainly argue that proton therapy decreases damage to surrounding tissue, reduces complications when treating certain tumors and provides cancer patients with lifesaving therapy; however, the reality is that payers may not necessarily weigh these arguments as heavily as clinical outcomes when determining reimbursement.

High Reimbursement Rates Limit Adoption
According to a 2012 Journal of the National Cancer Institute study, the median Medicare reimbursement for prostate cancer treatment using proton therapy of $32,428 was nearly twice the reimbursement of intensity-modulated radiation therapy (IMRT) at $18,575. In response to this large cost differential, major insurance companies announced they will no longer approve proton therapy to treat early-stage prostate cancer or will simply reimburse at IMRT rates. Prostate cancer was a prime example of putting the proton therapy “cart” (ie, patient demand, reimbursement expectations) before the “horse” (ie, clinical evidence). Not all tumors have suffered the same fate, but a few proton ventures that were based on prostate cancer volume collapsed as this played out.

Current proton facilities are now reading the playbook closely and responding to the need for more clinical evidence. This will ultimately lead to new growth areas for proton therapy. Sg2 expects proton therapy utilization for liver, gastrointestinal, esophageal, head and neck, lung, and breast cancers to grow significantly, albeit over small baseline volumes, over the next 5 to 10 years.

Emerging Advancements in Technology Are Critical
Beyond clinical evidence needs and reimbursement issues, proton therapy is just starting to catch up to traditional photon-based radiation therapy in terms of technological advancements. Unlike traditional radiation therapy, which benefits from volumetric imaging (eg, cone-beam CT), proton therapy has significantly lagged behind. Onboard imaging, which is standard on most photon-based linear accelerators, is missing on all but a few of the current proton treatment setups.

Today, proton facilities use radiography for patient positioning, portal imaging to confirm treatment and some have retrofitted volumetric imaging, but this is a labor-intensive and expensive process. For the most part, these facilities are currently treating “blind.” Additionally, where traditional linear accelerators have advanced capabilities to shape and contour the photon beam (eg, IMRT) proton facilities have relied on scattering foils to disperse the beam, with less targeted results. However, advancements in new proton therapy equipment include cone-beam CT, patient positioning and gating applications to ensure the beam is going exactly where it should. Intensity-modulated proton therapy (IMPT) is also being tested. New scanning beam nozzles in development will permit complex beam shaping needed for IMPT. These advancements in imaging accuracy and intensity modulation are critical to improve precision, drive the expansion of proton therapy into other tumor types and enable proton therapy to complete with traditional radiation therapy.

Modeling Proton Therapy Demand in Your Market
Having talked with a number of Sg2 clients recently about the impact of either acquiring their own proton facility or facing a competitor in the market that offers proton therapy, I thought it helpful to consider demand in a model market. What I discovered is that the analysis varies significantly by market, with the perception of proton therapy differing considerably among providers and even different patient populations.

Ultimately, if you were to open a proton therapy facility at your institution tomorrow, you would draw patients to treat with proton equipment from 2 sources: 1) converting your existing photon therapy patients to proton therapy; and 2) growing your share of the radiation therapy market by offering this technology.

Consider these key questions in modeling proton therapy demand in your market.

  • What are the current referral patterns for pediatric cancer care?
  • What advanced linear accelerators are in your market?
  • How likely is it that aligned physicians and hospitals will give up their professional or technical revenue from treating cancer patients?
  • How would the availability of proton beam affect practice patterns? Are radiation oncologists pushing for this technology and excited about its potential?
  • What are the particular tumor types radiation oncologists are open to treating, as reflected by interest in developing protocols or participating in registries?
  • What additional markets could your organization draw from? How far is your reach? Where is the nearest existing proton center?
  • What is the likely reimbursement, given payers’ attitudes and understanding of proton beam?
  • What is the likely impact on other external beam radiation technology?
  • What partnership or financial structure options exist?


Sources: National Association for Proton Therapy Conference. New Orleans: January 19–22, 2016; Yu JB et al. J Natl Cancer Inst. 2013;105:25–32; Sg2 Analysis, 2016.

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As of February 11, 2016, Vizient, Inc. has completed its purchase of MedAssets Sg2 and spend and clinical resource management segments from Pamplona Capital Management, LLC. MedAssets revenue cycle business will continue to operate as a wholly-owned subsidiary of Pamplona Capital Management LLP.

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