Proton Beam Therapy Poised for Growth in US

Fueled by patient demand and advances in technology, the construction of costly proton beam centers is picking up steam. Insurers are paying for limited applications.

With several countries charging ahead in efforts to build proton beam therapy centers for cancer radiation treatment, American healthcare providers and their partners appear poised to advance the technology beyond its infancy in this country.

"It's one of the areas where the U.S. is behind," says Jason Caron, a partner at Chicago-based law firm McDermott, Will and Emery, who has worked on proton beam therapy center projects for more than eight years. He noted that Japan is considered a leader in the field, with a dozen advanced particle beam radiation centers, including four centers using the most cutting-edge technology, carbon ion beams.

So far, 14 proton beam therapy centers have been built in the United States and a dozen more are in development, according to the Silver Spring, MD-based National Association for Proton Therapy. Most of the U.S. facilities have multiple examination rooms, which are built inside giant vaults that keep protons from escaping and causing harm to caregivers and others who work or live near the facilities.

Proton beam centers have a staggering capital cost. In February, the Scripps Proton Therapy Center opened in San Diego with a $220 million price tag, according to the project's developer, San Diego-based Advanced Particle Therapy.

Despite the cost, proton therapy is becoming widely accepted in the oncology community as a superior treatment for many cancers compared to traditional proton-based radiation treatment because protons can be targeted at a tumor without irradiating surrounding healthy tissue. "In breast cancer treatment, conventional therapy irradiates the heart as well as the tumor," he says. "Proton therapy does not irradiate the heart to any significant degree."

Unlike treatment with protons, which can pass through a patient's body, protons can be focused specifically on malignant tissue, says APT President and CEO Jeffrey Bordok. "The physics of protons versus protons are pretty hard to argue against. You're able to avoid damage to tissue around the tumor. There's a lot of evidence that this has been working over the past 20 years."

As more American patients have become aware of the less invasive technology, they are emerging as a key driver of proton beam center growth in the United States, Caron says.

"People are becoming educated about the benefits of proton therapy," he says. "It's not the best for all cancers, but if you have a cancer near a major structure or are very young, proton therapy is beneficial."

Leonard Arzt, executive director of the National Association for Proton Therapy, says consumer demand for the treatment has created a marketing opportunity for the top cancer centers in the country. "If you're in the radiation oncology business, you want the latest and greatest tool."

Proton beam center financing

Securing financing for proton beam centers remains the prime stumbling block for growth of the technology in the United States, but the capital-cost challenge is easing, say several experts in the field.

"There's no clear and simple model to do this," Arzt says. "In an age of healthcare reform and keeping costs down, banks are skeptical about the lofty goals of treating 2,000 patients per year."

Most "multi-room" U.S. proton beam centers cost about $200 million to build, and they treat approximately 1,500 patients annually. An emerging trend is construction of smaller proton beam centers with one examination room, at a cost of about $30 million, Arzt says. "The trend is away from multi-room facilities to 'compact machines.'"

There are three classes of proton beam center financing, according to Caron and Arzt.

Large healthcare providers are best equipped to follow the "institute model," in which a major hospital or health system obtains all of the financing for the project. Rochester, MN-based Mayo Clinic is building two proton beam centers with the assistance of a $100 million donation. "Only a Mayo Clinic can do that," Arzt says.

Joint ventures are the most complicated way to finance a proton beam center, according to Caron and others at McDermott, Will and Emery. Last spring, several proton beam center experts from the law firm led a presentation on financing these joint ventures. They noted that risks are difficult to align and distribute when multiple partners are involved in a proton beam center, such as health systems, equipment manufacturers, real estate firms, and banks.

The Scripps Proton Therapy Center was developed through a project manager model: Advanced Particle Therapy assumed the construction and maintenance costs, while San Diego-based Scripps Health is responsible for staffing and operating the facility. "We are responsible for providing all the equity and debt for the project," Bordok says.

Chris Van Gorder, president and CEO of Scripps Health, says the project manager agreement with APT provides the health system with a financially sustainable path to operating a proton beam center.

"Scripps Health's relationship with Advanced Particle Therapy is a great fit, because it gives Scripps the opportunity to offer advanced proton therapy to our patients without having to invest the significant capital required for this technology," he says. " We want to offer our patients the full range of cancer treatment options so they can have access to the one that is the best fit for their individual situation, close to home in San Diego."

Commercial payers getting on board

Several commercial insurance carriers are providing coverage for proton beam therapy.

"We do cover proton beam therapy for certain conditions, and costs are covered by the plan, except for appropriate copays, coinsurances, and deductibles depending on the member's benefits. This is a prior-authorized service managed for us by CareCore," said Donald Fischer, MD, MBA, senior vice president and chief medical officer at Pittsburgh-based Highmark Inc. "We have medical policy for this treatment documented online for all Highmark commercial members in Pennsylvania, West Virginia, and Delaware, as well as for our Medicare Advantage members."

According to Highmark's medical policy, the insurance carrier provides coverage of proton beam therapy for the following conditions: chordomas and chondrosarcomas of the base of the skull or spine; melanoma of the uveal tract (iris, ciliary body and choroid); hepatocellular carcinoma; pediatric brain tumors such as posterior fossa tumors, optic pathway tumors, and brainstem lesions; pediatric central nervous system tumors; and pediatric spinal tumors. 

But Cigna, which also works with Bluffton, SC-based CareCore National LLC to manage proton beam therapy coverage, reimburses the therapy for only three conditions, citing a lack of clinical evidence showing the treatment is superior to more conventional radiation therapy for most cancers. "While PBT has been used in patients in the United States since the mid-1950s, and although it has been shown to be effective in some malignancies, there is no published data clearly demonstrating superiority over conventional forms of radiation therapy," state the Bloomfield, CT-based carrier's guidelines for radiation therapy.