Provision Center for Proton Therapy Responds to the L.A. Times and the Wall Street Journal Articles


The Provision Center for Proton Therapy Response to the L.A. Times Article Dated August 28, 2013 and the Wall Street Journal Article of August 29, 2013 on Health Insurer Payment Policies for Proton Therapy – August 30, 2013

Articles in the week of August 26, 2013 in the Los Angeles Times and the Wall Street Journal concerning recent coverage changes by health insurance providers for proton therapy raised questions about the efficacy and cost effectiveness for treating prostate cancer. We believe these changes are short sighted and without merit and will provide the basis for our opinion below.

  1. The information used in the articles is flawed and incomplete. – The clinical papers referenced in the articles and used by the insurers in their recent reimbursement decisions have been refuted and shown to be in error by many proton therapy radiation oncologists. In direct response to Dr. Yu’s study mentioned in the article, Dr. Andrew Lee, director of the M.D. Anderson Proton Therapy Center stated that the study’s length, one year, wasn’t a long enough period to review all side effects from either treatment and that the study failed to say how many treatments were delivered. He added that if Yu is “willing to make recommendations or clinical judgment based on this sort of data, I think he is at risk to doing a disservice to his patients.”[1] Dr. Marcio Fagundes, Medical Director of the Provision Center for Proton Therapy and Dr. Allen Meek, Medical Director of the Provision Radiation Therapy, along with Medical Directors from 10 other proton therapy centers in the U.S., are in the process of preparing a detailed clinical response to the conclusions referenced in these articles. In the meantime, see the peer reviewed publication in the following link which provides more complete and accurate information: Click Here
  2. 99% of prostate cancer patients treated using proton therapy believe that they made the best treatment decisions for themselves. – According to a recent study, about 2,000 patients, representing about 20% of the 10,000 prostate cancer patients receiving proton therapy from 1991 through 2010 believe that they made the best treatment decisions for themselves. This study is referenced in the following link: Click Here
  3. The coverage change decisions for proton therapy for prostate cancer patients will impact many individual prostate cancer patients but will not have a significant impact on total reimbursement for proton therapy centers. – While these coverage change decisions by Aetna and Blue Cross/Blue Shield of California for proton therapy are not favorable, it does not reflect a significant impact to the total reimbursement landscape for proton therapy prostate cancer treatment. The main payer for cancer treatment in the United States is Medicare whose coverage policy includes payment for prostate cancer treatment. In addition, there are many commercial payers who have favorable coverage policies for proton therapy prostate cancer treatment including the nation’s second largest payer, Wellpoint. We believe that even if all commercial payers were to adopt this restrictive policy the impact would only affect 5-10% of current projected proton therapy patients. This impact could be even lower if our plans for reducing the cost for proton therapy for prostate cancer through hypo-fractionation are embraced by commercial payers as we believe they will. In addition, the high demand for proton therapy treatment and limited availability for other indications will simply mean that other non-prostate cancer patients will be treated rather than the prostate cancer patients who are not covered by their insurers.
  4. Costs for proton therapy for prostate cancer patients will soon be comparable with costs for conventional IMRT radiation therapy – In these articles, the Blue Cross Blue Shield representative makes the statement that proton therapy for prostate cancer treatment has the same clinical outcomes but it is more expensive. While we acknowledge that proton therapy is currently more expensive than Intensity Modulated Radiation Therapy (IMRT), this can be negated by the use of hypo-fractionation. Hypo-fractionation is not new to the field of radiation oncology and is commonly used to treat many different cancers with a fewer number of treatments utilizing higher doses per treatment resulting in fewer total number of treatments. This technique can be accomplished by delivering the treatments with greater precision and accuracy. This level of precision is already inherent in proton therapy treatment delivery and thus hypo-fractionation is a prime candidate for use in cancers such as prostate cancer. Thus, the utilization of hypo-fractionation for prostate cancer treatment results in fewer treatments and thus reduces the cost to current IMRT rates or below thereby negating the “more expensive” argument for proton therapy use for prostate cancer.
  5. The significant benefit of Intensity Modulated PROTON Therapy is now beginning to be realized – There is no disputing that IMRT has become a mature technology since its introduction in 1998. With proton therapy equipment manufacturers recently making available Pencil Beam Scanning for proton beam delivery, Intensity Modulated Proton Therapy (IMPT) is now a clinical reality and is being used in the clinical environment. Just like the maturation of IMRT, significant improvements in radiation dose delivery can be expected with IMPT thus further supporting its superiority to conventional radiation therapy. Dr. Anthony Zeitman, former President of ASTRO and current editor of the International Journal of Radiation Oncology, Biology, & Physics, recently stated in June that improvements over IMRT can be exceeded with intensity modulated protons.[2]
  6. There is increased risk to healthy tissue receiving unnecessary radiation. – There is no denying the science when comparing proton therapy and conventional x-ray therapy. Dr. Herman Suit stated it eloquently in his 2001 Grey Lecture when he stated, “No advantage to ANY patient for ANY irradiation of ANY normal tissue exists” and he further shared that “Radiation complications NEVER occur in un-irradiated tissues.” The visual comparison below even further demonstrates the significant advantages of the use of proton therapy to deliver less radiation to normal healthy tissue.

Note the additional unnecessary radiation dose (blue/green colored area) to healthy tissue with conventional radiation therapy in the top picture as compared to the unnecessary radiation dose from proton therapy in the bottom picture. In particular, note the additional unnecessary radiation dose to the rectum in the right side pictures.

  1. Proton therapy for prostate cancer treatment reduces the risk of secondary cancers in addition to reducing debilitating side effects such as impotence and incontinence – A crucial advantage for the use of proton therapy for prostate cancer is conveniently ignored by the commercial payers and article authors. In 2009, a significant study was published by M.D. Anderson Cancer Center assessing the risk of secondary cancers caused by scatter radiation from prostate cancer treatment. That study demonstrated that proton therapy reduced the risk of a secondary cancer by 26-39% compared with IMRT. This reduction was attributed to the substantial sparing of the rectum and bladder from exposure to the therapeutic beam by proton therapy. Why is this significant? With over 200,000 men diagnosed annually with prostate cancer in the United States even a small incidence of secondary cancers would result in a significant number of men developing secondary cancers. In addition, complications using proton therapy for prostate cancer treatment are reduced from 60% with IMRT to 12% for proton therapy. The M.D. Anderson study is referenced in the following link: Click Here

In today’s world it is common knowledge that less radiation causes less harm. Whether from radiation safety principles such as ALARA (As Low As Reasonably Achievable), efforts by the US Government to reduce the amount of radiation delivered from a diagnostic CT scan, or concerns about low levels of radiation from airport security scanners, significant awareness and efforts are being enacted to reduce any amount of radiation to normal healthy tissues. Thus it is a unique paradox as to why the same principle does not hold true with critics of proton therapy. Nonetheless, the clinical research for proton therapy continues to develop and grow and will in time differentiate from IMRT and prove it is a more effective therapy. During this period we will use methods such as hypo-fractionation to negate the argument that proton therapy is not cost effective.

The Provision Center for Proton Therapy physicians and staff believe that physicians, patients, and payers should rely on the facts concerning proton therapy, and we offer you these facts to help in your decisions concerning proton therapy. For additional information, see our website at: and the “Proton Guys” website at: or call us at (865) 862-1600 or toll free at (855) 566-1600.

[1] Stokes, Trevor. “No fewer side effects for prostate proton therapy.” Reuters News Service 12.27.12

[2] Zietman A. Proton Beam and prostate cancer: An evolving debate. Rep Pract Oncol Radiotherapy (2013)