National Trend Bucked, Protons Nixed in Oregon

Nick Mulcahy

December 27, 2012

One of the largest medical centers in the Pacific Northwest is bucking a national trend and will not to build a proton-beam therapy center.

The Oregon Health and Science University in Portland has decided to forgo the costly technology, reported the Oregonian last week.

There are 20 new proton-beam centers, which can cost up to $100 million or more, in the building or planning stages in the United States. These will add to the 10 centers currently in operation.

Oregon Health and Science University is not joining the crowd. But it gave the proton-beam modality some serious consideration, particularly for the treatment of prostate cancer.

"All of us were interested in exploring it," said Tomasz Beer, MD, deputy director of the Knight Cancer Institute at the university, in the report.

Dr. Beer did not say whether his institution's decision was influenced by the planned federal budget cuts to radiation oncology.

Medicare reimbursement for proton therapy will be cut by nearly one third. As a result, centers' per-patient revenue will drop from an estimated $36,000 to $25,000, according to the report.

Dr. Beer's published comments focused on treatment-related issues with proton radiotherapy.

"It's not clear today whether proton therapy offers a meaningful and substantial clinical advantage," he said about its efficacy in prostate cancer.

Dr. Beer's concerns have been borne out in a couple of recent studies.

Earlier this month, researchers at Yale University School of Medicine in New Haven, Connecticut, reported that the incidence of urinary complications at 6 months post treatment was slightly lower for men with prostate cancer treated with proton radiotherapy than for men treated with intensity-modulated radiotherapy (IMRT).

However, the benefit was fleeting. Twelve months after treatment, there was no longer any difference between the 2 technologies. There was also no difference in the rate of other common side effects of radiation treatment for prostate cancer, including erectile dysfunction, hip fractures, gastrointestinal issues, or musculoskeletal problems, according to the study, which was published online December 20th in the Journal of the National Cancer Institute.

These results somewhat echoed those of another recent study, which was presented in November at the annual meeting of the American Society for Radiation Oncology.

Men with prostate cancer who were treated with proton-beam therapy had better quality-of-life scores in the first few months after treatment than those treated with 2 more common modalities. But, again, the benefit was transient, as the scores evened out at 1 and 2 years, as reported by Medscape Medical News. The study, from a team at Harvard University in Boston, Massachusetts, used data from 3 different patient cohorts because there has been no direct comparison of proton-beam therapy, 3D conformal radiation therapy, and IMRT.

Portland Seers or Losers?

It remains to be seen whether Oregon Health and Sciences University will lose out on prostate cancer patients in the future, should a proton radiotherapy center be built in its market.

A recent study suggests that patients are attracted to proton-beam treatment if it is convenient. Men diagnosed with localized prostate cancer were more likely to be treated with proton-beam therapy if the technology was available nearby, the study found.

Nearly 9% of the potential patients (from 2003-2006) living within the referral region for the proton-beam facility at Loma Linda University in southern California received the therapy, compared with less than 2% of patients throughout the rest of the state, as reported by Medscape Medical News.

But Dr. Beer and his Portland colleagues may turn out to be seers if the technology is not proven to be superior in outcomes or side effects.

A prospective, randomized controlled trial to investigate differences between conventional radiotherapy modalities and proton-beam therapy is now underway at the Massachusetts General Hospital in Boston and the University of Pennsylvania in Philadelphia. The trial will compare proton radiotherapy and IMRT for patients with localized prostate cancer and is expected to open at several other proton centers in 2013.

In the meantime, a prominent oncologist earlier this year decried the lack of evidence supporting the superiority of proton therapy over IMRT, and its cost.

Ezekiel Emanuel, MD, from the University of Pennsylvania, who is a former adviser to President Barack Obama, described the ongoing building of proton-beam therapy units in the United States as a "medical arms race" and "crazy medicine and unsustainable public policy."

In a New York Times online opinion piece, Dr. Emanuel wrote: "If the United States is ever going to control its healthcare costs, we have to demand better evidence of effectiveness and stop handing out taxpayer dollars with no questions asked."