if the advocates for PBRT as a safer and more effective form of treatment for localized prostate cancer than other forms of radiation therapy want payers to be convinced that PBRT really is better than modern IMRT, they need to become a great deal more active in convincing patients to participate in the ongoing clinical trial that has been designed to prove this point.
Is proton beam therapy for prostate cancer worth the cost?
With this limited availability and no evidence that proton therapy is better, why is use of the procedure rising at such a feverish pace? Financial incentives may be playing a role. Proton beam therapy for prostate cancer is reimbursed at a much higher rate than traditional radiation treatment for the same condition. Medicare pays about $19,000 for a full dose of standard radiation therapy for prostate cancer, but it pays nearly double for proton therapy - more than $32,000.
Prostate cancer has become far and away the most common condition for which a Medicare beneficiary receives proton beam therapy, accounting for 2 of every 3 claims and 80% of Medicare spending on the procedure. So while the cost to build a treatment center is high, proton therapy presents a lucrative opportunity for those who are willing to make the investment. Established facilities in the US report annual revenue approaching $50 million. This profit potential is leading to a veritable "arms race" in the field, with the number of facilities in the US expected to double in the next few years.
Given the rising cost of US healthcare it is increasingly important to prove through studies that paying more is associated with better outcomes. A great deal of research is currently underway to determine whether proton beam therapy for prostate cancer can fulfill the hope of saving livings while limiting side effects and complications. However, men who are choosing treatment today should be aware that proton therapy's hoped-for benefits have not yet been proven. Meanwhile these men (as well as Medicare and other insurers) should reasonably ask, "Does it make sense to get the same results yet pay twice as much?"
Insurer Medical Policies - unproven and not medically necessary
United Healthcare Medical Policy - Proton_Beam_Radiation_Therapy.pdfAetna Proton Beam and Neutron Beam RadiotherapyProton beam radiation therapy is unproven and not medically necessary for treating ALL other indications, including but not limited to:
- Age related macular degeneration (AMD)
:::- Prostate cancer
- Vestibular tumors (e.g. acoustic neuroma or vestibular schwannoma)
Aetna considers proton beam radiotherapy for treatment of prostate cancer not medically necessary for individuals with localized prostate cancer because it has not been proven to be more effective than other radiotherapy modalities for this indication. Proton beam therapy for metastatic prostate cancer is considered experimental and investigational.Wellmark - Proton Beam Radiation Therapy
Proton beam therapy as a treatment for prostate cancer is considered not medically necessary because the clinical outcomes with this treatment have not been shown to be superior or more effective than the other radiotherapy modalities for this indication.
Alberta Health - Clinical Practice Guideline -proton-beam-rt.pdf
Members of the working group do not currently recommend that patients with prostate cancer, non-small cell lung cancer, or most lymphomas be referred for proton beam radiotherapy, due to an insufficient evidence base. However, individual patient cases should be discussed by the multidisciplinary team during a Tumor Board meeting.
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