Everyone seems to agree that proton beam therapy–a type of radiation that can attack cancerous tumors while generally sparing the surrounding tissue–is an exciting technology with a lot of potential. But some insurers and disease experts say that, until there’s better evidence that proton therapy is more effective at treating various cancers than traditional types of less expensive radiation, coverage shouldn’t be routine.
That approach doesn’t sit well with proponents, some of whom say that insurance coverage is critical for necessary research of the controversial therapy’s uses.
Meanwhile, the number of proton therapy centers — huge structures that can cost more than $200 million — continues to increase. Fourteen are in operation in the United States and a dozen more under development, according to Leonard Arzt, executive director of the National Association for Proton Therapy.
Critics assert that the rush to build the centers is putting a very large cart before the horse.
In general, “the evidence has failed to demonstrate that there is a significant improvement in outcomes with proton beams,” says J. Leonard Lichtenfeld, deputy chief medical officer at the American Cancer Society. “It’s fair to question whether the number of facilities that are being constructed really reflect the proven value of proton beam therapy.”
A 2012 study published in the journal Radiotherapy and Oncology, for example, found proton beam therapy to be superior to traditional photon therapy for some childhood cancers affecting the central nervous system as well as large cancers of the eye and tumors at the base of the skull. In the case of prostate and liver cancers, there was evidence that the therapy worked, but not that it was superior to photon-based treatment, according to the study. It found that there wasn’t enough evidence to recommend the proton beam therapy for lung cancer, head and neck cancer, gastrointestinal malignancies and other pediatric cancers.
In addition, a 2013 study of Medicare patients published in the Journal of the National Cancer Institute found the cost of proton beam therapy to treat prostate cancer was roughly 70 percent more than photon therapy. Experts say costs are often even higher, with a course of proton beam treatment running three to six times the cost of conventional radiation.
The use of proton beam therapy has accelerated rapidly in recent years as medical centers have raced to capitalize on its clinical and financial potential. At the same time, those efforts have drawn increasing criticism from some consumer and health care advocates who suggest that the therapy is a clear illustration of how new technology can drive costs higher for consumers and insurers without necessarily improving care.
Last month, the proton beam center at the University of Indiana, one of the country’s first, announced it was closing. Among the reasons were the center’s aging equipment, the large number of newly designed facilities and falling insurance reimbursements.
Prostate cancer has become a particularly controversial coverage area. The most common cancer among men, it accounts for roughly a third of patients at proton centers, and even more at some centers, says Arzt. But research has generally failed to show that proton therapy results in better outcomes or fewer side effects than traditional radiation despite its higher cost, and some insurers have stopped covering it for prostate cancer.
Insurance coverage for proton beam therapy varies widely and changes as research emerges. Some insurers, such as Cigna, cover proton therapy only for cancer of the eye. Others, including UnitedHealthcare, cover the therapy for additional conditions, including skull-based tumors and arteriovenous malformations in the brain as well as some pediatric illnesses. Although Medicare doesn’t have a national coverage policy for proton therapy, the therapy is generally covered with few limitations, according to a spokesman for the Centers for Medicare & Medicaid Services.
Some advocates for proton beam therapy say insurers need to provide more support for the clinical trials that they believe will show the treatment is superior.
Steven Frank, the medical director of the proton therapy center at the MD Anderson Cancer Center in Houston, is trying to recruit patients for a randomized clinical trial to test proton therapy against photon therapy in head and neck cancer.
“The biggest struggle we’re coming up against is that the insurers don’t want to pay for it,” he says.
Under the health law, most insurers are required to cover routine patient costs associated with participating in approved clinical trials for cancer or other life-threatening conditions. So if a patient suffers side effects or other medical problems during the trial, insurers are responsible for covering those costs, among others. But they don’t have to pay for costs related to the investigational part of the trial, in this case the pricey proton beam therapy.
Some say this situation is no different than testing a cancer drug: The insurer covers the routine costs, but the drug manufacturer is often responsible for providing the drug and testing it.
“Drugs should prove whether they are equal or superior to an existing treatment,” says Lichtenfeld. “Why should proton beam be any different?”
Proton beam therapy proponents counter that it is different because they already know the therapy works.
How the standoff will be resolved is unclear, but as long as it continues and research isn’t conducted to evaluate which type of therapy works best, there’s one clear loser: the patient.
This story was updated at 9:50 a.m. to add information in the final graph.
Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.