ASTRO to Medicare, Insurers: Pay for These Proton Treatments

Nick Mulcahy

June 04, 2014

Proton-beam therapy (PBT) should be reimbursed by Medicare and private insurers for a variety of cancers, according to a new policy from the American Society for Radiation Oncology (ASTRO).

The policy is issued at a time when PBT continues to be very controversial in the United States because of its high cost and the relative lack of evidence supporting its superiority over other forms of radiotherapy.

The policy appears to be an attempt to both secure coverage for PBT and provide a rationale for that coverage.

Specifically, ASTRO now recommends that payers provide coverage for 2 types of cancer patient groups.

Coverage group 1 consists of patients with diagnoses for which PBT has "been proven to be effective," such as pediatric cancers, particularly those in the brain, and certain adult cancers, such as ocular melanoma, according to an ASTRO press statement.

Coverage group 2 consists of cancer patients enrolled in clinical trials or multi-institutional registries that are studying PBT to collect data for the development of scientific evidence. This would include patients enrolled in clinical trials of PBT for the treatment of prostate cancer.

The recommendation about prostate cancer is not new.

The organization previously released a similar statement on the use of PBT for prostate cancer. In addition, in 2013, as part of the Choosing Wisely campaign, ASTRO issued list of 5 radiation oncology practices that should stop, which included a call to end the use of PBT for the treatment of prostate cancer — unless the therapy is in the context of a clinical trial.

The use of PBT in prostate cancer has been especially controversial and has resulted in some insurers issuing policies of their own, refusing to pay for PBT.

The specific cancers in group 1 have been chosen on the basis of published clinical data and "medical necessity requirements," according to the ASTRO policy.

Medical necessity refers to, among other circumstances, instances in which PBT is "considered reasonable" because "sparing the surrounding normal tissue cannot be adequately achieved with photon-based radiotherapy."

Group 1 Cancers Recommended for Coverage
Ocular tumors, including intraocular melanomas
Base of the skull tumors, including chordoma and chondrosarcomas
Tumors of the spine
Hepatocellular cancers
Pediatric solid tumors
Tumors associated with genetic syndromes, such as neurofibromatosis type 1 cancers and retinoblastomas

 

Group 2 potentially consists of a much larger group of patients.

Group 2 Cancers Recommended for Coverage
Head and neck malignancies
Thoracic malignancies
Abdominal malignancies
Pelvic malignancies, including genitourinary, gynecologic, and gastrointestinal cancers

 

"Proton beam therapy is demonstrating promise in our continuing efforts to improve survival and cure rates for cancer patients while reducing side effects," said Colleen A.F. Lawton, MD, FASTRO, chair of the board of directors for ASTRO, in the press statement. "As the leading experts in radiation oncology, it is important for ASTRO to provide balanced, evidence-based guidance to payers that ensures access to PBT for cancer patients while being judicious stewards of our nation's and our patients' financial resources."

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