When University of Kansas Hospital leaders announced the purchase of a $40 million proton beam therapy machine this month, they also entered one of the biggest controversies in cancer care.
President and CEO Bob Page described it as a major boon for area patients. KU will be the first hospital in the region to have one of the high-tech, room-sized devices for delivering targeted radiation.
“We have reached another key milestone in our work to transform the way healthcare is delivered in our city, state and region,” Page said. “We are joining an elite group of health systems and hospitals offering this leading technology.”
But some experts had a far less optimistic take.
“Yes, you will be the first” in the region with a proton beam center, said Ezekiel Emanuel, an oncologist and bioethicist at the University of Pennsylvania’s Perelman School of Medicine. “You may also be the first to close it, you may be the first to lose money on it. There are a lot of firsts here to be had.”
Radiation oncologists — the cancer doctors who use proton beam machines — have largely embraced them as a technological breakthrough that can deliver the tumor-fighting benefits of radiation with less harm to surrounding tissues.
But other medical experts say the rapid growth of the proton beam industry is emblematic of what’s wrong with the market-driven U.S. approach to health care.
Aside from pediatric cancers and a few rare types of adult tumors, science hasn’t proven that proton beams are better than older, much cheaper treatments, they say. But the proliferation of proton centers means they must be used for more common cancers, or go under financially.
Amitabh Chandra, a health economist at Harvard University, likened proton beam to “the Death Star of American medical technology” in a 2012 interview with Bloomberg, calling it “a metaphor for all the problems we have in American medicine.”
KU officials say those critiques are outdated — that the Proteus One system they’re buying from Belgium-based IBA is more compact and economical than older versions and that research is finding more and more uses for it every year.
The unit — not expected to be operational until 2021 — is a natural and necessary purchase for a National Cancer Institute-affiliated academic medical center, said Terry Tsue, vice president and physician-in-chief of KU’s Cancer Center.
“This is all part of bringing the best technology and the best armamentarium to treat cancer patients,” Tsue said.
Roy Jensen, the director of the University of Kansas Cancer Center, called it “one of the most exciting new technologies to come onboard for the treatment of cancer.
“Making sure our patients have access to this treatment option is essential,” Jensen said.
But Emanuel, who formerly served as chief of bioethics at the National Institutes of Health, said it’s not necessary for every NCI cancer center to have a proton beam machine.
“It’s a prestige item more than it is a therapeutically necessary item,” he said. “It’s hardly a slam dunk financially, (and) it’s hardly a slam dunk medically.”
Emanuel, whose institution offers proton beam, said there aren’t enough cancer cases that legitimately call for it to support the 27 proton beam centers in the nation last year, much less the 20-plus that were under construction.
With patients in short supply, some centers are struggling financially, and at least one has closed. Others are pushing proton beam therapy for cancers that are far more common, but for which it’s far less proven effective.
“That’s inefficiently delivered care and that’s not something we should be sanctioning or encouraging,” Emanuel said. “We all end up paying for inefficiently delivered care. It’s called higher (insurance) premiums.”
There’s no debate that proton therapy is beneficial for a small subset of cancer patients, including kids and those with cancer of the brain, eyes or spine.
A promotional video released by KU Hospital highlighted one such patient, an 8-year boy named Roman Volkov.
“Instead of patients like Roman leaving the area for this kind of care, they’ll be able to access this state-of-the-art treatment right here in Kansas City,” said Tammy Peterman, the hospital’s chief operating officer, chief nursing officer.
Right now the nearest proton beam treatment centers are in St. Louis and Oklahoma City, meaning that most everyone in Kansas and Missouri lives within 250 miles of one.
Emanuel said that countries with more government controls in their health care system have found that it’s more cost-effective to pay for patients like Roman to travel that sort of distance for proton therapy — and to put their family up in a hotel for a couple months.
“In many countries they wouldn’t build another machine within 250 miles,” Emanuel said. “They would just send everyone within that catchment area to an existing one.”
That’s not how medicine works in the U.S., said Shannon Brownlee, co-founder of the Right Care Alliance and senior vice president of the Lown Institute, a Massachusetts-based health policy think tank.
Brownlee, the author of “Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer,” said that U.S. hospitals are competing for patients in a more open market, and when they have to refer patients elsewhere, they lose out on revenue. So they want to keep patients in-house, especially if they have an illness that’s particularly lucrative to treat, like cancer.
Brownlee also said that while some patients would certainly find it appealing to get their cancer care closer to home, having fewer proton beam centers each treating more patients would probably be better for them medically.
“The reality is, if you are one of the rare adult cancers that can be treated more effectively with this machine, it’s a lot better to send you to a place that does it all the time and has a lot of experience with it,” Brownlee said.
Tsue, the KU Cancer Center vice president, said that doesn’t account for studies that show patients fare better when they’re treated near their support network of family and friends.
He also said comparisons to other countries were flawed.
“I think we’re in a very different health system,” Tsue said. “I think our patients deserve more.”
KU Hospital doesn’t just plan to use proton beam for rare cancers.
Hospital spokeswoman Jill Chadwick said the American Society for Radiation Oncology recommends proton beam therapy for some of the most common types of cancer, like breast, lung and prostate, as well as the rare cases in the spine and brain.
In all, Chadwick listed off 10 types of cancer for which KU’s proton beam therapy could be used.
“We also plan to do research around proton therapy to help further identify the most appropriate use in additional cancers, and so our opportunities to treat different cancers will likely grow,” Chadwick said via email.
Emanuel burst out in laughter when he heard KU’s list over the phone.
“Prostate (cancer): No evidence it’s better. Absolutely none,” Emanuel said. “Lung, breast, all these things are under-studied.”
He said his institution is part of clinical trials to see whether proton beam therapy is better than older treatments specifically for breast cancers on the left side, where stray radiation could potentially damage heart tissue. But no conclusions have been drawn.
A similar study at Georgetown University, published in January, found no better survival rates for breast cancer patients treated with proton beam therapy.
A study published last year by the MD Anderson Cancer Center in Houston found that it’s no better than traditional treatments for lung cancer either.
The radiation oncology society’s model policy on proton beam therapy states that it should always be considered a medical necessity for head and neck tumors and childhood cancers, and insurance companies should also cover it for things like breast cancer and prostate cancer as long as they’re part of research studies.
But Brownlee of the Right Care Alliance said the research that’s been done so far — including a wide-ranging 2014 report by the Institute for Clinical Economic Review — doesn’t support that.
“You just don’t see the benefits in the data,” Brownlee said. “So I can’t for the life of me figure out why all these radiation oncologists are jumping on this bandwagon.”
“The medical community knows best, there is no good reason to ever radiate healthy tissue if it can be avoided,” Chadwick said, “and proton beam therapy offers the best option for preserving healthy tissue in treating many cancers.”
Despite the radiation oncology society’s recommendations to use proton beam for several types of cancers, many insurance companies have been reluctant to approve the treatments in the less proven cases — especially prostate cancer.
That has caused increasing financial pressure on the industry as the number of patients fails to match up with the number of machines in service.
Proton therapy centers in Baltimore, San Diego, Virginia, Tennessee, New Jersey, Oklahoma City, Seattle and Chicago have struggled to break even, according to Kaiser Health News, with some of them restructuring debts related to building the machines, or even defaulting on them.
The Indiana University Proton Therapy Center closed in December 2014, rather than investing in the upgrades it would have needed to keep operating.
But Peter Johnstone, the president of that center at the time it closed, said that was a special case. The facility had been using a decades-old repurposed cyclotron from the Indiana University physics department that took a small army of people to maintain, Johnstone said, and the university president decided to invest in other priorities rather than buying one of the new commercial versions.
The Indiana proton center was solvent when it closed, Johnstone said, and KU’s should be in the black within five years of installation.
“In any moderate-sized city you could probably support a single proton room, as long as people realize it’s a very unique asset and people from other health care systems may need to send their patients there,” said Johnstone, who is now vice chair of the radiation oncology department at the Moffitt Cancer Center in Tampa, Florida.
Most of the proton centers that are now struggling financially were built to treat multiple patients at the same time. The Baltimore facility, for example, includes five proton machines at a cost of $200 million.
That’s a far cry from what’s going to be built at KU Hospital, which is only dipping its toe into the shallowest end of the proton beam pool for now.
Jeff Wright, the hospital’s vice president of cancer care, said KU started looking at proton therapy as far back as 2007, but the financials didn’t make sense until companies started making compact units like the one IBA is selling KU for $40 million — a price that includes long-term maintenance..
The hospital also plans to renovate the existing radiation oncology building on its main campus at 4000 Cambridge Ave., so IBA can install the machine there. But KU officials don’t expect the total costs of construction and equipment to be more than $50 million.
Wright said that after 12 years of study, KU is confident that enough paying patients will support a single proton machine, and maybe a second one in the future.
“We remain very excited about offering our patients the latest technology and keeping them from having to travel for their care,” Wright said.
University Hospitals in Cleveland has reportedly exceeded its break-even target of 18 patients per day with a similarly-priced machine. (Its world-renowned competitor, the Cleveland Clinic, said last year it’s not planning to add the technology because the evidence for it is lacking.)
But recent developments in Washington, D.C., could make it even harder for proton beam therapy centers to make it financially.
Medicare has generally been one of the most reliable payers for the treatments (even though Medpac, a panel of experts that advises the federal government on health care coverage, has called it a prime example of “low-value care”).
That could change under a new federal rule that affects all radiation oncology payments.
Rather than paying oncologists based on the number of scans and procedures they do, the new rule would pay them a bundled base rate for treating specific types of cancers. It’s part of an ongoing effort by Medicare to move away from “fee-for-service” payments to reimbursements based on the quality and value of care.
The rule isn’t in effect yet, but Brandon Henry, an analyst with RBC Capital Markets who tracks the health care sector, said the rule will represent “a large change in radiation oncology reimbursement.”
“I’d say this new payment rule could make the environment for proton therapy tougher going forward,” Henry said.
Whether the new proton therapy center at KU Hospital makes money or not, Brownlee said the people of Kansas City will end up paying for it.
Insurance premiums will go up if insurers are generous in their coverage, she said. If they’re not, then KU Hospital could end up having to cut into other areas to subsidize a money-losing machine.
“There’s real harm in spending money on something that’s not better and is more expensive,” Brownlee said, “and that harm is that hospital is not investing in something else that could improve its community or improve the health of more patients.”