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Report: Insurers Hesitant to Cover High-Priced Proton Beam Therapy

Studies question cancer efficacy

Proton beam therapy (PBT) — a type of radiation that can attack cancerous tumors while generally sparing the surrounding tissue — appears to have a lot of potential. But some insurers and disease experts say that, until there’s better evidence that PBT 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 on the controversial therapy’s uses.

Meanwhile, the number of proton therapy centers — huge structures that can cost more than $200 million — continues to rise. Fourteen are in operation in the U.S., and a dozen more are under development, according to Dr. 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.

“The evidence has failed to demonstrate that there is a significant improvement in outcomes with proton beams,” says Dr. J. Leonard Lichtenfeld, deputy chief medical officer at the American Cancer Society. “It’s fair to question whether the number of facilities that is being constructed really reflect the proven value of proton beam therapy.”

A 2012 study published in Radiotherapy and Oncology, for example, found PBT to be superior to traditional photon therapy for some childhood cancers affecting the central nervous system as well as for large cancers of the eye and for 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. The report stated that there wasn’t enough evidence to recommend PBT 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 that the cost of PBT to treat prostate cancer was approximately 70% more than that of 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 PBT 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 that it was closing. Among the reasons were the center’s aging equipment, the large number of newly designed facilities, and falling insurance reimbursements.

Insurance coverage for PBT varies widely and changes as research emerges. Some insurers, such as Cigna, cover PBT only for cancer of the eye. Others, including UnitedHealthcare, cover the treatment 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 PBT, the therapy is generally covered with few limitations, according to a spokesman for the Centers for Medicare & Medicaid Services.

“Drugs should prove whether they are equal or superior to an existing treatment,” Lichtenfeld says. “Why should proton beam be any different?”

PBT proponents counter that it is different because they already know the therapy works.

How the standoff will be resolved is unclear, but as research isn’t being conducted to evaluate which type of therapy works best, there is one clear loser: the patient.

Source: Kaiser Health News; September 23, 2014.

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