Proton Therapy for Prostate Cancer

INTRODUCTION:




On October 5, 1954 the NYT on page 29 posted an article entitled,”Mass of Protons Fired into Brain; First Test of Kind is Made in Last Desperate Effort to Save a Cancer Patient.” This was how and when proton therapy for cancer originated in the US as a treatment modality for cancer patients.

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MECHANISM:




Proton beams used to treat patients are generated in a cyclotron. The advantage of high energy protons and other heavy charged particles is that its dose is deposited evenly throughout the pathway of the radiation beam’s entry until it reached the end of its range where it falls off completely into a “Bragg peak.” This is different from photon radiation because a photon is a very small entity, the comparison to the size of a proton would be on the order of the difference between the size of a grain of sand and the size of the Empire State Building. If one thinks of the human body being made up of a very large city’s worth of buildings the reason the grain of sand (photon) can navigate the city and come out the other side becomes apparent. It also becomes apparent that when large charged particles such as proton’s traverse the human body they eventually stop in a very precise place.




HISTORY:




In the mid-1990’s 16,000 patients had been treated with proton therapy for cancer. At that time most proton therapy centers were affiliated with large physics research facilities. The proton’s effect on the human body was of particular interest to NASA and space flight because during any trip outside of the protection of the Earth’s ionosphere will subject space travelers to proton radiation. The first hospital based proton facility was built at the Loma Linda University Medical Center. It was designed and built by the Fermilab. The congressman Jerry Lewis helped the Loma Linda University secure federal dollars for the $80 million dollar facility. On December 29th, 1988 Fermilab first operated Loma Linda’s proton accelerator and it treated its first patient in October of 1990.




Below are links to several articles about the history of Proton therapy:

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HEALTH POLICY IMPLICATIONS OF PROTONS:




Based on a presentation by Timothy Williams MD, President-elect of ASTRO, at a conference convened to discuss the economic impact of proton therapy on the field of medicine it was revealed that since 2001 the Medicare part B portion of the budget used to pay for radiotherapy had increased 97% to 1.599 billion dollar in 2006. IMRT radiation was responsible for 823 million dollars in expenses. It was also reported at this meeting that the charge per daily proton radiation fraction was $1011 which was higher than the $631 for IMRT. The estimated cost of prostate cancer treatment for a single patient was $50,000 for protons, $35,000 for IMRT and $15,000 for brachytherapy. Several private companies have entered the proton therapy business including IBA, Hitachi, Accel, Varian and Still River.




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A CASE STUDY OF A MODERN PROTON FACILITY:




Belgium based IBA Proton Therapy Group built and maintains the $50 million proton beam therapy system at the $125 million Proton Beam Therapy Institute at Shands Hospital in Jacksonville, Florida. IBA based upon its 2007 investor relations report had 213,849,000 (Euros) in sales and a 69,845,000 (euros) gross margin. IBA expects to sell 2-3 facilities in the U.S. until 2010 when it expects to sell 10 a year. Below are links to the websites of the other competing proton facility manufacturers – I highlight IBA because it accounts for 50% of the current world market.




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INSURANCE COVERAGE DEBATE:




Of interest Medicare is considering the proposition to no longer fund proton therapy for prostate cancer. Medicare does this from time to time for treatments. The results of Medicare’s judgment will likely determine the availability of proton therapy for patients with prostate cancer going into the future. I have provided a link to the public comments regarding proton therapy and several recent news paper articles about this controversy for your reference.




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THE EVIDENCE FOR PROTON RADIATION FOR PROSTATE CANCER:




In terms of efficacy, there are few reports of efficacy of proton treatment for prostate cancer. I have given link outs below to pertinent papers presented as abstracts and available in medical journals. I will continue to add to the list of links regarding outcomes data for your reference as the evidence is made available to the medical community:



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