July 23rd, 2019
As the University of Kansas Hospital prepares to proudly unveil their new proton beam machine, they should also be preparing to answer some tough questions about the cost and effectiveness of this therapy. In The Wichita Eagle, health policy experts Shannon Brownlee, Senior Vice President at the Lown Institute, and Ezekiel Emanuel, oncologist and bioethicist at the University of Pennsylvania’s Perelman School of Medicine, add a dose of healthy skepticism to the hospital’s hype-filled announcement.
Proton beam machines have become increasingly popular investments for health systems, despite the lack of evidence to support the use of proton beam therapy (PBT) for all but a few types of cancer. Comprehensive reviews of the evidence by the independent nonprofit Institute for Clinical and Economic Review in 2014 and the American Society of Radiation Oncology in 2012 found evidence of net benefit from PBT only for ocular tumors, brain and spinal tumors, and pediatric cancers, compared to standard radiation treatment.
Even more recent research hasn’t helped the case for PBT. A 2016 report from the Canadian Agency for Drugs and Technology found that “overall, none of the clinical evidence was suggestive of a substantial incremental benefit of PBT over photon radiotherapies.” In 2016, the first randomized controlled trial for PBT for lung cancer found it no more effective than conventional radiation therapy and no less toxic. And a 2018 systematic review of quality of life and patient-reported outcomes after PBT found increased benefit only for certain brain, head and neck, lung, and pediatric cancers.
As Emanuel points out, there aren’t enough patients with ocular, brain, or pediatric cancers to warrant so many proton beam machines in the region. So why do hospitals keep building them? Because hospitals would rather refer patients in-house than lose cancer patients to other health centers, explained Brownlee. Unfortunately, as we’ve seen with complications at some pediatric surgery centers, having more centers that conduct fewer procedures each actually increases the chance of complications.
“The reality is, if you are one of the rare adult cancers that can be treated more effectively with this machine, it’s a lot better to send you to a place that does it all the time and has a lot of experience with it,” Brownlee said.
Increasing investments in unproven therapies like PBT is not just a financial risk for the hospital–it increases health care costs for everyone. If insurers pay for PBT (which they are being increasingly pressured to do), insurance premiums will go up. If they don’t pay for PBT, the hospital may cut into other areas to cover their costs. And perhaps most importantly, we have to take into account the enormous opportunity cost of investing in PBT rather than more impactful community health initiatives.
“There’s real harm in spending money on something that’s not better and is more expensive,” Brownlee said, “and that harm is that hospital is not investing in something else that could improve its community or improve the health of more patients.”