Proton-Beam Therapy: Snags in US but Expanding Globally

Proton-beam therapy centers are proliferating around the world, despite remaining questions over what advantages it offers over conventional radiotherapy.

While it provides a high degree of precision, allowing an escalated radiation dose to be targeted directly on a tumor while sparing the adjacent healthy tissue, it remains controversial because of its high cost and limited evidence on how it compares with other forms of radiotherapy, as previously reported by Medscape Medical News.

The United States has the most proton-beam therapy centers, with 28 in operation, a jump from just 11 in 2013. In addition, 23 more are under construction or in development.

However, proton-beam therapy centers may be experiencing "growing pains," according to a feature article published July 12 in the Lancet Oncology. Patient demand for the technology has been much lower than anticipated in some centers, and several centers have been grappling with financial losses or have missed financial targets, the authors report. For example, the Scripps Proton Treatment Center in San Diego, California, declared bankruptcy, is no longer affiliated with Scripps, and is now under new management.

A recent article from Kaiser Health News reported other centers with financial struggles, including one at Indiana University that closed in 2014, and several that have been losing money and restructuring their debt. The Hampton University Proton Therapy Institute in Virginia has lost money for at least 5 years in a row, recording an operating loss of $3 million in its most recent fiscal year, the article noted.

Growing Globally

Despite the struggles in the US marketplace, proton-beam therapy centers are proliferating worldwide.

There are 63 facilities in operation, with 32 facilities under construction, and 16 more are in the planning stages of development, according to the Particle Therapy Co-operative Group, a nonprofit organization. With Argentina and Australia soon to be added to the roster, there will eventually be proton centers on every continent other than Antarctica.

About 165,000 patients with a variety of cancer types have been treated with proton-beam therapy, and in their latest global forecast, Research & Markets predicts that it is on track to become a multibillion-dollar industry by 2024. The group estimates sales to reach between $2.3 to $4.3 billion by 2030, with 900 to 1300 particle therapy treatment rooms open to patients worldwide. The number of centers is anticipated to continue increasing each year.

In Europe, the market more than tripled between 2010 and 2017, and proton-beam therapy is being used for solid tumors, including those of the brain, spine, prostate, and stomach. Germany, Italy, Sweden, France, Denmark, the Netherlands, Switzerland, Russia, Spain, the United Kingdom, Norway, and Belgium are all setting up new centers or are in the planning stages. The European proton-beam therapy market is likely to continue growing from now until 2024, the Research & Markets group predicts.

About 60% of the global population resides in Asia, and it accounts for about half of the global cancer burden. The market in Asia for proton-beam therapy is also anticipated to increase at a double-digit growth rate from 2018 to 2024. While Japan currently has the largest number of centers in Asia, new facilities are under construction or in the development stages in China, Singapore, Thailand, and South Korea.

The first proton-beam therapy center in the Middle East/North Africa region has opened in Saudi Arabia, and another one is under construction in the United Arab Emirates. Egypt is planning a center at the Children's Cancer Hospital Foundation in Cairo, and Israel has just announced that it will be finalizing plans to build a center. The Israeli Health Ministry estimated that approximately 250 patients will be treated annually in Israel, including 150 children. Building the facility will cost about $60 million, and another $6 million will be needed to operate it.

Arriving Down Under

A newcomer to the proton-beam therapy market is Australia, which has its first center in development in the city of Adelaide.

"The federal government has committed funding to the center in Adelaide," said Scott Penfold, PhD, a medical physicist at the Royal Adelaide Hospital and University of Adelaide. "This is the only project that has received federal funding at this stage," he told Medscape Medical News.

He noted that the center is still in development and will not be in operation until 2021 at the earliest. As far as additional centers in the future, that will depend somewhat on the success of the one in Adelaide.

"We currently send patients, and their carers if required, overseas to receive proton therapy if it is deemed advantageous," Penfold explained. "This is very costly considering the distances to be traveled. Opening of the other centers will certainly depend on demand for the service."

An important consideration is whether the Australian healthcare system here, known as Medicare, will pay for proton-beam therapy. "We recently had a consultation report written to examine the evidence for proton therapy," he said. "The report is currently receiving consumer responses and a final recommendation to the Health Minister is expected at the end of this year."

Penfold added that they are hoping that at a minimum, patients who are funded to travel overseas will be covered by Medicare when a center opens in Australia. "We also hope for future consideration of wider indications," he added.

Limited Access Up North

Despite some of the financial woes, the United States is forecast to maintain its dominant position in the proton-beam therapy market. But its neighbor to the North has not shown much interest in expanding its proton-beam therapy capacity.

Canada has one only facility, located in Vancouver, British Columbia (BC), which is primarily a research center. TRIUMF is Canada's national particle accelerator center and a leading subatomic physics facility on an international level. Patients are treated there, but in a very limited capacity.

Cornelia Hoehr, PhD, Proton Therapy Manager at TRIUMF, told Medscape Medical News that they treat patients with choroidal melanomas, which are located at the back of the eye, and have done so since 1995.

"Our center is a collaboration between TRIUMF, the Eye Care Centre at the University of British Columbia and BC Cancer," she said. "We are an older proton therapy center, and we only treat about 10 patients a year."

Hoehr noted that they do not have any imminent plans to expand to treat other indications. "The BC health care system coves the cost for BC patient, and many other provinces do have agreements with BC to cover as well," she said.

Hoehr also explained that they do have the capacity to treat more than 10 patients a year, and in fact, their ophthalmologist sees about 40 patients or so a year. "But she chooses to treat three quarters with brachytherapy, and only one fourth with the biggest tumors or tumors close to sensitive organs like the optic nerve are referred to TRIUMF," she explained.

She added that there is "talk" about opening proton-beam therapy centers in Toronto or Montreal, given the very long distances patients living in the eastern provinces must travel to be treated in Vancouver. "For certain indications, Canadian cancer patients are referred to US centers," she said.

Still a Niche Market

Despite the growing global number of proton-beam therapy centers, however, it is still very much a niche market and represents only about 1% of all the external radiotherapy systems installed worldwide.

In 2017, just over 0.1% of all patients with cancer were treated with this modality, and by 2022, it is estimated that there will still be only 0.5 proton therapy treatment rooms per 10 million people worldwide, vs about 20 radiotherapy systems per 10 million patients.

By 2030, even if the projected 900 to 1300 treatment rooms will be available, that will still allow only 6% to 7% of patients with cancer to receive proton therapy treatment.

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