The decision to shutter a proton beam therapy center in Indiana is shining light on the precarious financing of the costly facilities used to treat some cancers.
The planned closure of the Indiana University Health Proton Therapy Center early next year is unlikely to derail investments in the costly cancer-fighting technology across the country, according to officials at the university and the National Association for Proton Therapy.
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IU officials announced the decision to close the Bloomington facility for financial reasons last month based on the recommendation of an independent review panel.
The IU Health Proton Therapy Center, which is the third-oldest proton beam facility for tumor treatment in the country, has been spilling red ink on the university's balance sheet since it opened in 2004. IU has already lost $20 million on the facility and could lose as much as $15 million more, university officials said in the prepared statement announcing the closure decision.
Insurers Hesitant To Cover Many Proton Beam Therapy Treatments
Earlier this week, a university official said the IU Health Proton Therapy Center faces insurmountable financial pressure.
"This center was one of the first of its kind in the United States, but the competition has increased significantly in the last several years, which has affected patient volumes," said Mark Land, associate VP of public affairs and government relations at IU.
"The facility, which is a bit unusual in that it is not located in a hospital, but rather is a free-standing facility that was created to make additional use of the proton beam at the IU Cyclotron, has operated at a financial loss for most of its existence. It would take a significant investment to make the facility cost competitive with new centers with no reasonable hope that such an investment would ever be recouped," he said.
Land describes the circumstances involved in the development and operation of the IU Health Proton Therapy Center that placed the facility at a competitive disadvantage. "As I understand it, proton therapy centers today are being constructed primarily within hospitals and for specific purposes. In our case, we had an existing proton beam and used that as an opportunity to provide patient care. While that allowed us to get into the field, it's not the way you'd build it today."
Construction costs for PBT centers range as high as $200 million for facilities with multiple treatment rooms from about $30 million for "compact machines" with a single treatment room, says Leonard Arzt, executive director of the National Association for Proton Therapy in Silver Spring, MD.
He contends that the impending closure of the IU Health facility is not a bad omen for PBT in the United States.
"The Indiana proton center faced financial challenges from the beginning when it opened about a decade ago. It started with a very old cyclotron in a physics research facility that eventually needed costly upgrading and maintenance," Arzt said.
"The closure will have minimal to no impact on the proton community outside of Indiana. There are currently 14 operating centers across the United States, with a dozen more currently in development. … We are confident proton facilities are here to stay for the long-term treatment and benefit of cancer patients worldwide."
Not Aging Gracefully
Whether or not the closure of the IU Health Proton Therapy Center is the beginning of a negative trend, the findings of the review panel that examined the facility's viability tell a cautionary tale.
The panel found that the oldest U.S. proton beam therapy facilities face financial and technological challenges. "This facility is outdated and requires significant investment to continue to operate. Because of both the expense of these investments and the high operating costs of an aging facility, it does not appear that IUHPTC can ever achieve a positive margin," the review panel members wrote in their report.
The panel asserted that the IU Health Proton Therapy Center is at a significant disadvantage compared to newer facilities. "Although the replacement of the cyclotron would permit the facility to continue to function, it would not permit the development of state-of-the-art technology, which would require multiple other components," the review panel members wrote.
The oldest proton therapy center for cancer treatment opened in California at Loma Linda University Medical Center in 1991. Massachusetts General Hospital has the nation's second-oldest proton therapy center, with its facility opening in 2000.
A Proton 'Bubble?'
In terms of technology, the review panel found PBT is facing stiff competition from refinement of older technologies and from development of new radiation therapies.
The panel noted that historically standard radiation therapy based on photon physics "has closed the gap with proton beam to an unanticipated degree." The panel also noted the development of potentially superior technologies such as carbon ion beam facilities.
Based in part on these finding, the panel drew a disturbing conclusion about the country's oldest and most debt-ridden proton therapy centers. "It is, therefore, quite possible that we are on the verge of a 'proton bubble' with the more indebted centers or those without a strong patient supply line closing. Those with less or no debt, or those built around academic institutions, will likely survive," the report says.
The Cost-effectiveness Debate
The IU Health Proton Therapy Center review panel noted that cost-effectiveness and efficacy remains an open question and high-risk proposition for proton beam cancer treatment.
"The fact that any proton facility costs 10 to 100 times as much as the next most expensive medical device has placed it in the center of the debate about value-based medicine and some insurers are starting to balk at the cost and to decline coverage."
PBT advocates say it should be the standard of care for isolated tumors, particularly in children, because proton beams can be focused on cancerous tissue while sparing adjacent healthy tissue.
There are no U.S. randomized clinical studies demonstrating "proof in principle" that proton beam therapy is superior to other forms of cancer treatment, the panel concluded.
PBT advocates believe randomized studies currently underway in the U.S. will show the technology is cost-effective.
A study published in May in the International Journal of Radiation Oncology suggests that for head and neck tumors, "early clinical outcomes are encouraging and warrant further investigation of proton therapy in prospective clinical trials."
Christopher Cheney is the CMO editor at HealthLeaders.