Roxanne Nelson
Aug 30, 2013
Proton-beam therapy,
which is used primarily in the United States, is a controversial alternative to
conventional radiotherapy for cancer patients. Proponents argue that it is
safer and results in fewer complications and less damage to healthy tissue, but
opponents say that, in most cases, the supporting evidence just isn't there,
especially considering the exorbitant cost.
The
controversy has now reached another level. According toa report in
the Wall Street Journal, insurers are now balking at the cost.
Two major insurance companies have announced that they no will longer pick up
the tab for proton-beam therapy to treat early-stage prostate cancer. A third
has joined the fray, saying it will be reviewing its policy later this year.
Blue
Shield of California has notified 300 radiation oncology and urology practices
in the state that, as of the end of October, it will no longer cover
proton-beam therapy for prostate cancer. Ironically, this decision comes just
as Scripps Health in San Diego is preparing to open its new proton-beam therapy center,
which will be the second in California and the twelfth in the country.
Aetna
Inc., the nation's third-largest insurer, stopped covering the procedure for
prostate cancer on August 1, and Cigna Corp. says it is planning to review
its policy on the therapy later this year.
These are not the
first insurers to discontinue coverage. Three years ago, Regence, a BlueCross
Blue Shield insurer that operates in 4 states, stopped its coverage for this
indication, and Highmark Inc., Pittsburgh, and Blue Cross and Blue Shield of
Kansas City do not cover it.
Cost and Lack of Evidence
The
major issue with proton therapy is the
cost of the treatment
and of the treatment facility.
The
cost to equip and construct a suitable proton center can range from $25 to
$150 million. The acquisition cost for intensity-modulated radiation
therapy (IMRT) systems is far less pricey, ranging from $1.8 to
$5.4 million, according to a 2009 report by the Institute for Clinical and
Economic Review on management options for low-risk prostate cancer.
The
treatment also has a much higher price tag. Some data show that for prostate
cancer, the median Medicare reimbursement for proton therapy is $32,428 and for
IMRT is $18,575.
Although
many experts agree that some patients are good candidates for proton therapy —
most notably children with central nervous system tumors — its use in prostate
cancer is highly controversial.
One
expert at the 2013 Annual Meeting of the American Society of Clinical Oncology
went so far as to say that "proton radiotherapy sells
hope, but there is no clear measurable benefit that we can actually
translate and explain to a patient."
"I
think you've been spending money on something that, at the moment, doesn't
deliver. It may deliver in the future, but that will probably be after my
retirement," Frank H. Saran, MD, from the Royal Marsden NHS
Foundation Trust in the United Kingdom, told the mainly American audience at
the meeting.
Even
though proton therapy is supposed to focus the beams more tightly and thereby
reduce complication rates, there is no real evidence for this, explained Gerald
Chodak, MD, director of the Midwest Prostate and Urology Health Center in
Michiana Shores, Indiana, in a Medscape videoblog
posted earlier this
year.
Proton
therapy "is a technology that is at least 30% more costly than IMRT, with
no clear evidence that it does reduce long-term side effects and absolutely no
data to show that it provides better outcomes," he said.
And,
although some centers have been using this technology for a substantial period
of time, "we have yet to see a single report talking about long-term
mortality," Dr. Chodak added.
Hanging in There
But
not all insurers are throwing in the towel. Notably, the federally funded
Medicare program is continuing to pay for proton therapy for patients with prostate
cancer, and they have not announced any changes in that coverage. However,
according to the Hospital Outpatient Prospective Payment System rule for 2013,
Medicare did reduce
its reimbursementrate for proton therapy.
The
mean payment for proton therapy was reduced from $1549 in 2012 to $682 in 2013.
This means a 32% drop in revenue, from an average of $35,917 per patient to a
projected average of $24,565 per patient, according to the Advisory Board
Company, a research and consulting firm.
WellPoint
Inc., the second-largest insurance company in the United States, will also
continue to cover the procedure, but is negotiating the cost down. Kristin
Binns, a spokesperson for WellPoint quoted in the Wall
Street Journal report,
said that the cost of proton therapy is now comparable to other forms of radiation therapy,
at least in some parts of the country. She also said that WellPoint considers
proton therapy to be "medically necessary" in certain situations.
Blue
Shield is also not throwing in the towel completely. Like WellPoint, it believes
that proton therapy has advantages for certain patients, and it will continue
to cover the treatment when clinical evidence supports its use, such as in
children with certain tumors.
