Protons vs. Photons: A Battlefield Update

Many controversies are raging currently in the world of prostate cancer diagnosis and treatment, ranging from PSA screening to robotic vs. laparoscopic surgery.  But certainly the battle with the highest economic stakes is the long-running war between traditional photon-based (X-ray) Electron Beam Therapy (EBT) and Proton Beam Therapy (PBT) for treating prostate tumors.

gunfightBoth methods have proven highly capable at eradicating cancers of all kinds.  One way to look at the difference between the two technologies is to turn to the gunshot analysis seen frequently on TV crime procedurals.  Both EBT and PBT are “guns” that use invisible high energy “bullets” to kill cancer cells. EBT is the radiation equivalent of a “through and through” gunshot: the high energy photons go into the body, through the organ—let’s say a prostate—and then back out the other side. Like its real life equivalent, EBT can injure other healthy organs on its way out.  PBT, on the other hand, is like a bullet that enters, but does not exit the body, accurately “landing” its cancer-destructive energy right at the targeted organ itself. Proponents of using PBT to treat prostate cancer argue that this soft landing reduces or may even eliminate side effects such as bladder irritation and ongoing rectal issues common to “more primitive” EBT.

According the American Society for Radiation Oncology—ASTRO—PBT is especially effective on ocular cancers, cancers in children (who cannot tolerate EBT side effects as well as adults), tumors located at the base of the skull and other hard-to-reach places, abdominal tumors and the like.  But the tumor most commonly treated on PBT equipment is…prostate cancer.

Men who have been treated via PBT frequently approach religious fervor in their enthusiastic endorsement of the method.  Statements such as, “I got Proton Treatment, and would do it again. I recommend it to all that ask. All the hype for it was evidenced in my lack of side effects. I’m a believer!” can be found frequently at online prostate cancer patient forums.

So is PBT as effective at eliminating side effects as its believers and medical proponents assert?  Even though PBT has been in use for around 15 years, there have been no studies that demonstrate a clear superiority for PBT over EBT.  In 2012, ASTRO’s Emerging Technology Committee issued a report stating, “In prostate cancer there is evidence for the efficacy of PBT but no suggestion that it is superior to photon based approaches.”  In other words, the fight between PBT and EBT–officially, anyway–is a draw. They both work equally well.

All well and good, except for one big problem. The average EBT installation costs somewhere around $5 to $7 million, while PBT installations now cost upward of $235 million. There are currently 14 PBT centers in the US with another 10 under construction.  To obtain a profitable return on that investment, PBT centers must keep the couches positioned under all those proton beams filled with patients.  Since prostate cancer is the most widely diagnosed solid tumor cancer in men, at more than 230,000 diagnoses each year, prostate cancer treatment has been paying the most of the PBT bills up to now.  Since most prostate cancer patients are older men, Medicare has certainly aided investors in PBT centers with their return on nvestment as it reimburses the average PBT treatment course at $32,000 compared to about $19,000 for EBT.

Back in 2007, Anthony Zeitman of the Department of Radiation Oncology at the Massachusetts General Hospital (which itself possesses a PBT installation, so technology envy is not at work here) to sense some form of imminent economic disaster.  Writing in the Journal of Clinical Oncology, in an editorial titled “The Titanic and the Iceberg: Prostate Proton Therapy and Health Care Economics” he cautioned, “The expansive vigor of medical innovation is heading inexorably toward the harsh reality of economic fact. The controversial treatment of prostate cancer [between PBT and EBT] epitomizes this clash… Sailing forward, powered by the winds of advocacy, of market forces, and of high-stakes investment, is proton therapy, the proud vanguard of modern technology.  Elsewhere, waiting patiently in the darkness, are the hard, cold, unyielding laws of economics.”

The economic iceberg may now be looming closer to the PBT Titanic.

In July 2014, the journal, The Lancet Oncology, editorialized about PBT economics in a far more apocalyptic tone than Dr. Zeitman, observing sternly, “Certain reforms in the US health-care system have been championed by Medicare to drive down costs, but there is little sense in continuing to reimburse almost double for a treatment that has no proven benefit over more economic alternatives.”  Advocates of PBT argue that lower Medicare reimbursements will make it more difficult to cover the costs of constructing and running PBT facilities, to which the same editorial retorts,  “Medicare’s role is not to fund expensive treatment in the hope that it becomes cheaper in the long run.”

Some insurance companies are beginning to back away form reimbursing for PBT when EBT seems to be just as effective and significantly less expensive. In this era of increasingly constrained medical resources, the Lancet editorial writers are blunt in speaking to PBT marketers and advocates that “…deluding patients with false hopes of much more effective treatment with vastly reduced side-effects must stop; pumping huge sums of money from limited health-care budgets into unnecessarily expensive treatments is morally repugnant.”

It’s probably worth noting also that the ever-increasing costs of the Affordable Care Act (aka Obamacare) are to be funded in part by concomitant reductions in Medicare spending.  Reimbursing the same amount for prostate cancer radiotherapy regardless of the technology employed seems a logical place to obtain some significant cost savings.

So, what do you think should happen next, if anything?


  1. says

    I love this quote: “Medicare’s role is not to fund expensive treatment in the hope that it becomes cheaper in the long run.”

    What do i think should happen next. I think we should scrap the Affordable Care Act, get rid of running a health care system by insurance and do what most civilized nations have done for its citizens.

    Oh, that wasn’t what you aksed???

    • says

      Thomas: I intended to question to be open-ended. And I happen to totally agree with your recommendation.

      I keep wondering whoever thought that combining an unwieldy and generally incompetent government bureaucracy with profit-seeking insurance companies was a good idea. Much needed reform probably won’t happen in our lifetime, but I hold out hope for my children and grandchildren.

  2. says

    Of course, most civilized nations would have done it for THEIR citizens…

    Just two days ago I conversed with my GP, who claims that at 212 total cholesterol I am at risk before even going into the percentage thingies that they now do between HDL and total and LDL and total. I tried the argument that I do not have high blood pressure, have never smoked, and have no record of cardiac disease running through my family–why aren’t those factors considered mitigating.

    Because the numbers don;t lie…

    Then, i presented why i don;t want to take statins. he recommended red rice yeast or red yeast rice, or whatever. So looked it up. The main ingredient in that natural product, which is a by-product of rice processing, the main ingredient is the extract that the pharmaceutical industry uses to create statin drugs. It’s a statin!

    I lose confidence in the medical profession daily, but they do have statistics down.

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