Proton Pricing/Protons for Breast Discussion

[radiation]

List Prices for Proton Radiation Therapy

Some patients elect for self-pay proton radiation therapy (PT) in the United States, but price transparency is a significant concern. The U.S. governm…

www.sciencedirect.com

at least someone is talking about it. Expect to see Fumiko Chino publish about a million of these chargemaster papers going forward

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[medgator]

List Prices for Proton Radiation Therapy

Some patients elect for self-pay proton radiation therapy (PT) in the United States, but price transparency is a significant concern. The U.S. governm…

www.sciencedirect.com

at least someone is talking about it. Expect to see Fumiko Chino publish about a million of these chargemaster papers going forward

View attachment 352447
View attachment 352448

Many centers deliver an entire course of radiation for less than a single fraction of protons. Simply amazing. Curative or palliative, too

 

[TheWallnerus]

40 fractions of proton prostate (trust me, it’s a thing) at $15K per fraction

Do the math

Great work if you can get it!

 

[jondunn]

the proton lobby giveth and the proton lobby taketh

If any of the proton cabal is reading this - I am not saying a word here! I am one of the good ones. Pick me/Save me!

 

[madchemist89]

Isn't xrt like 150-200 dollars per fraction?

 

[deleted941485]

List Prices for Proton Radiation Therapy

Some patients elect for self-pay proton radiation therapy (PT) in the United States, but price transparency is a significant concern. The U.S. governm…

www.sciencedirect.com

at least someone is talking about it. Expect to see Fumiko Chino publish about a million of these chargemaster papers going forward

View attachment 352447
View attachment 352448

Charge masters are a joke. What are the ins actually paying?

 

[deleted1111261]

I think the article is focusing on self-pay - that’s the whole point. Because people are paying out of pocket.

 

[deleted941485]

40 fractions of proton prostate (trust me, it’s a thing) at $15K per fraction

Do the math

Great work if you can get it!

Unfortunately they only have this at the mothership too far for most patients. And nobody is paying out of pocket for this.

 

[deleted941485]

I think the article is focusing on self-pay - that’s the whole point. Because people are paying out of pocket.

How large is this population paying out of pocket for proton versus everyone else?

Even photons the only people I’ve ever seen pay for it are international globe trotters who think they are getting special treatment the US. And they paying charge master prices no questions asked. These are like the last group of people id worry about if I was overcharging or using some kind of geographic arbitrage on.

 

[communitydoc13]

Charge masters are a joke. What are the ins actually paying?

I don't think they're a joke, but they aren't what most payors are paying. I think the charge is roughly equivalent to the highest negotiated price that an institution can get for a service. This is why there is so much disparity. The highest charge we had from another thread was from UPENN, which is in the mid-Atlantic region.

I'm not sure how much the charge reflects the out of pocket cost, as the hospital may wisely set a "best price" for out of pocket payors (who are presumably largely international) as lower than the highest negotiated price with insurance.

Can't speak for UPENN, but multiple other academic places in the mid-Atlantic have a pretty burgeoning medical tourism VIP crowd. Not chump change.

 

[jondunn]

I think the article is focusing on self-pay - that’s the whole point. Because people are paying out of pocket.

I don't think this is true. They list charge master prices. when it comes to self pay they say this:

'Additionally, gross charges and actual “cash” or self-pay prices can differ, as facilities may offer a discount which could be open to negotiation.'


chargemaster are chargemaster. Honestly not sure how useful this is to determine what people or insurance companies are paying.

to me the most notable findings are that chargemaster prices are higher for proton than photon in most individual places, and that proton prices vary wildly between hospitals (just like all medical care)

 

[TheWallnerus]

When it takes more significant digits to specify the price of a radiotherapy fraction than it does the dose, we’ve got a problem

 

[medgator]

How large is this population paying out of pocket for proton versus everyone else?

Even photons the only people I’ve ever seen pay for it are international globe trotters who think they are getting special treatment the US. And they paying charge master prices no questions asked. These are like the last group of people id worry about if I was overcharging or using some kind of geographic arbitrage on.

A few of the 💩 insurances we take have huge OOP deductibles or only cover X number of "visits" for radiation, so it gets pretty close to what a self pay patient might pay

 

[temujim]

List Prices for Proton Radiation Therapy

Some patients elect for self-pay proton radiation therapy (PT) in the United States, but price transparency is a significant concern. The U.S. governm…

www.sciencedirect.com

at least someone is talking about it. Expect to see Fumiko Chino publish about a million of these chargemaster papers going forward

View attachment 352447
View attachment 352448

Looking at this, would rather pull my center up by getting protons rather than dragging down those who already do.

 

[OTN]

Unfortunately they only have this at the mothership too far for most patients. And nobody is paying out of pocket for this.

Some do indeed pay out of pocket for protons for prostate cancer.

 

[jondunn]

 

[RadOncDoc21]

Man, it’s getting personal… these days someone might get slapped.

 

[deleted1111261]

ITS NOT EVEN MY DATA!

He did the equivalent to me what Will Smith did to Chris Rock

 

[Palex80]

Answers like this disturb me, however.

"Happy to put in for auth". For a right sided breast. For a right sided breast.

 

[Gfunk6]

Man, it’s getting personal… these days someone might get slapped.

 

[RSAOaky]

Answers like this disturb me, however.

"Happy to put in for auth". For a right sided breast. For a right sided breast.

I get the sentiment, but I think it can be helpful to flip the switch. If your wife or daughter's insurance approved protons for a R sided breast, and it was fully covered for them either way, would you have them get photons?

The issue here isn't that there's no benefit to protons for a R sided breast, it's that there's not enough clinical benefit to justify the higher cost. I'm sure that dosimetrically the plans look better, are more homogeneous, and have better lung sparing

The real question for Jim Urbanic is as follows: if insurance companies DID approve all R sided breast tangents, but they were only willing to pay the equivalent of a photon treatment for it, would you be inundating your cyclotron with R sided breasts? If payments were neutral, the response would be "well there's no proven benefit to protons in this situation, and because it's such a limited resource we reserve it for patients that truly benefit like pediatric patients and some CNS tumors."

 

[RSAOaky]

Proton Elites: Those aren't the numbers at all! That's what we charge, but not what we get paid!
Photon Peasants: So what do you guys get paid? What's your $/QALY for Protons vs. Photons? What percentage of your proton collections are spent re-irradiating patients in their last 1-2 years of life?
Proton Elites: THAT'S PRIVATE!

 

[CurbYourExpectations]

I believe it. I got a job at a medium size hospital for $650K in 2010, with full benefits and retirement matching that probably added extra ~$100K a year, with no problem. At first they acted like they were going to buy me a house lol (never pushed for it). And admin said it was all in line with MGMA 75%ile. I had heard I was making more than the hospital's employed CT surgeon. (And when I left, they gave me $100K for being a nice guy.) Try and find that nowadays.

Probably unpopular take, but imagine a radonc making more than a CT surgeon

 

[TheWallnerus]

The issue here isn't that there's no benefit to protons for a R sided breast, it's that there's not enough clinical benefit to justify the higher cost. I'm sure that dosimetrically the plans look better, are more homogeneous, and have better lung sparing

No way I would "let" anyone get breast proton treatment. I don't care what the pretty pictures look like on screen: we care way too much about this instead of real clinical data. What with all the hand-waving over the uncertainties w/ protons, and how "tried and true" and "best by test" photons are... protons are tantamount to reckless human experimentation in breast cancer. Yes, I just said that. Think about it... the only reason we accept this sort of thing (protons in early stage breast) is sort of the only reason Will Smith got to sit through the entire ceremony last night and got a bunch of hugs and emotional support from everyone right after the incident. "The devil attacks you at the top of the Bragg peak" is what is happening on Twitter.

In one of the largest multi-institutional retrospective study by Wahl et al., which recorded outcomes for breast cancer patients with local recurrence after re-irradiation with X-rays, a lower percentage of the cohort experienced acute Grade 3–4 skin toxicities compared to [protons]

In a comparison with patients receiving photon radiation, a significantly higher rate of grade ≥2 [dermatitis] was observed in patients undergoing proton radiation

 

[temujim]

No way I would "let" anyone get breast proton treatment. I don't care what the pretty pictures look like on screen: we care way too much about this instead of real clinical data. What with all the hand-waving over the uncertainties w/ protons, and how "tried and true" and "best by test" photons are... protons are tantamount to reckless human experimentation in breast cancer. Yes, I just said that. Think about it... the only reason we accept this sort of thing (protons in early stage breast) is sort of the only reason Will Smith got to sit through the entire ceremony last night and got a bunch of hugs and emotional support from everyone right after the incident. "The devil attacks you at the top of the Bragg peak" is what is happening on Twitter.

In one of the largest multi-institutional retrospective study by Wahl et al., which recorded outcomes for breast cancer patients with local recurrence after re-irradiation with X-rays, a lower percentage of the cohort experienced acute Grade 3–4 skin toxicities compared to [protons]

In a comparison with patients receiving photon radiation, a significantly higher rate of grade ≥2 [dermatitis] was observed in patients undergoing proton radiation

From the first paper: "those in the PBT group being more likely to receive 1.8 Gy per fraction than 2.0 Gy per fraction"

Sadly very little explanation of the underlying proton techniques...

 

[jondunn]

These private places that got proton have really ruined it. The place in Tennessee, the scam artists in Shreveport, thr chicago group…..

1.8s and proton for all!

 

[medgator]

These private places that got proton have really ruined it. The place in Tennessee, the scam artists in Shreveport, thr chicago group…..

1.8s and proton for all!

Ignoring the crap out of Loma Linda? They weren't exactly giving state of the art prostate tx over a decade ago afaik.

C'mon JD....i know the academic satellite treats you well and feeds your belly, but try to be a little more objective here

 

[jondunn]

Loma Linda is trash too.

I won’t talk about your podunk center here!

 

[Palex80]

I get the sentiment, but I think it can be helpful to flip the switch. If your wife or daughter's insurance approved protons for a R sided breast, and it was fully covered for them either way, would you have them get photons?

Yes, I would.

The money you are taking out of the system to pay for right sided breast protons (or any other nonsense treatment) does not grow on trees.

I am also a bit concerned about chest wall toxicity with protons.

The real question for Jim Urbanic is as follows: if insurance companies DID approve all R sided breast tangents, but they were only willing to pay the equivalent of a photon treatment for it, would you be inundating your cyclotron with R sided breasts? If payments were neutral, the response would be "well there's no proven benefit to protons in this situation, and because it's such a limited resource we reserve it for patients that truly benefit like pediatric patients and some CNS tumors."

True!

 

[RSAOaky]

No way I would "let" anyone get breast proton treatment. I don't care what the pretty pictures look like on screen: we care way too much about this instead of real clinical data. What with all the hand-waving over the uncertainties w/ protons, and how "tried and true" and "best by test" photons are... protons are tantamount to reckless human experimentation in breast cancer. Yes, I just said that. Think about it... the only reason we accept this sort of thing (protons in early stage breast) is sort of the only reason Will Smith got to sit through the entire ceremony last night and got a bunch of hugs and emotional support from everyone right after the incident. "The devil attacks you at the top of the Bragg peak" is what is happening on Twitter.

In one of the largest multi-institutional retrospective study by Wahl et al., which recorded outcomes for breast cancer patients with local recurrence after re-irradiation with X-rays, a lower percentage of the cohort experienced acute Grade 3–4 skin toxicities compared to [protons]

In a comparison with patients receiving photon radiation, a significantly higher rate of grade ≥2 [dermatitis] was observed in patients undergoing proton radiation

Yes, I would.

The money you are taking out of the system to pay for right sided breast protons (or any other nonsense treatment) does not grow on trees.

I am also a bit concerned about chest wall toxicity with protons.

True!

I'm not up on the proton breast data, but if you believe it to be an inferior treatment in some way then it's a bit of a moot point, we obviously should not be giving more expensive inferior treatments. I made my post assuming that protons were equivalent at worst and dosimetrically but not clinically superior at best, which I'm sure is what those in the proton world believe. If this were the case, I'd have a hard time choosing photons over protons for a family member, all else being equal, just to be a good steward of insurance dollars.

 

[Mandelin Rain]

Protons for right sided breast is Choosing Poorly.

 

[elementaryschooleconomics]

With ASTRO still clinging to a 10-year-old document which has locked us into 3D for breast...

...remind me how proton$ came into the conver$ation?

 

[jondunn]

using imrt for everything will just make the reimbursement for imrt go down, but that is going to happen anyways.

 

[deleted1111261]

using imrt for everything will just make the reimbursement for imrt go down, but that is going to happen anyways.

I agree with using it more often (as long as people know how to contour). This is where an APM (not The APM, an APM) model can help. Treatment charge/reimbursement is essentially fixed, but you can treat as you see fit.

 

[metallica81788]

Often colleagues ask how I get such high quality IMRT approved for certain select palliative cases - never hurts to ask

 

[Palex80]

I'm not up on the proton breast data, but if you believe it to be an inferior treatment in some way then it's a bit of a moot point, we obviously should not be giving more expensive inferior treatments. I made my post assuming that protons were equivalent at worst and dosimetrically but not clinically superior at best, which I'm sure is what those in the proton world believe. If this were the case, I'd have a hard time choosing photons over protons for a family member, all else being equal, just to be a good steward of insurance dollars.

There is some data pointing in the direction of a rather high rate of rib fractures.

End-of-Range Radiobiological Effect on Rib Fractures in Patients Receiving Proton Therapy for Breast Cancer

A prospective trial of proton therapy for breast cancer revealed an increased rib fracture rate of 7%, which is higher than the expected rate based on the literature on photon therapies. We aim to evaluate the hypothesis that the increased relative biological ...

www.ncbi.nlm.nih.gov

Thirteen of 203 patients in the cohorts exhibited a total of 25 fractures.

Now, I am poor person and don't have protons for breast cancer. I have some proton experience, but I am certainly not an expert.
However, 13/203 = 6.4% of patients experiencing a rib fracture after proton radiotherapy for breast cancer is more than I see in my patients treated with photons.

Beware: This is a study utilizing older proton therapy techniques (passive scattering). It does however highlight a potential issue when using protons for breast cancer.

 

[RickyScott]

There is some data pointing in the direction of a rather high rate of rib fractures.

End-of-Range Radiobiological Effect on Rib Fractures in Patients Receiving Proton Therapy for Breast Cancer

A prospective trial of proton therapy for breast cancer revealed an increased rib fracture rate of 7%, which is higher than the expected rate based on the literature on photon therapies. We aim to evaluate the hypothesis that the increased relative biological ...

www.ncbi.nlm.nih.gov

Thirteen of 203 patients in the cohorts exhibited a total of 25 fractures.

Now, I am poor person and don't have protons for breast cancer. I have some proton experience, but I am certainly not an expert.
However, 13/203 = 6.4% of patients experiencing a rib fracture after proton radiotherapy for breast cancer is more than I see in my patients treated with photons.

Beware: This is a study utilizing older proton therapy techniques (passive scattering). It does however highlight a potential issue when using protons for breast cancer.

I hate the “older techniques” argument because at the time, proton centers were claiming to offfer better xrt. But this time we should believe them

 

[deleted1111261]

6.4% rib fracture rate! That has to be subclinical. I wonder what's the rate for photons?

 

[TheWallnerus]

I hate the “older techniques” argument because at the time, proton centers were claiming to offfer better xrt. But this time we should believe them

you're a very unfair person to use what people said in the past and hold them to account for it

 

[TheWallnerus]

6.4% rib fracture rate! That has to be subclinical. I wonder what's the rate for photons?

There's a proton study where something like 30% of the patients had a grade 2 or greater esophagitis. By patients I mean breast patients!

 

[deleted1111261]

Early toxicity in patients treated with postoperative proton therapy for locally advanced breast cancer - PubMed

Postoperative proton therapy is well tolerated, with acceptable rates of skin toxicity. Proton therapy favorably spares normal tissue without compromising target coverage. Further follow-up is necessary to assess for clinical outcomes and cardiopulmonary toxicities.

pubmed.ncbi.nlm.nih.gov

 

[RickyScott]

6.4% rib fracture rate! That has to be subclinical. I wonder what's the rate for photons?

I have only seen 2 rib fractures in my entire career. Both were from 20gy x 3 to peripheral lung tumor.

 

[Palex80]

6.4% rib fracture rate! That has to be subclinical. I wonder what's the rate for photons?

Randomized trial of breast irradiation schedules after lumpectomy for women with lymph node-negative breast cancer - PubMed

The more convenient 22-day fractionation schedule appears to be an acceptable alternative to the 35-day schedule.

pubmed.ncbi.nlm.nih.gov

The Whelan trial reported 1 rib fracture attributed to radiation therapy among 1234 randomized patients.
That would be 0.0814%

 

[SneakyBooger]

Sometimes wealth is inversely proportional to ignorance.

 

[deleted941485]

Sometimes wealth is inversely proportional to ignorance.

A lesson I learned too late.

 

[SneakyBooger]

Young fellow I am treating for prostate cancer right now asks: "Dr. Booger, do you think protons are better than photons for prostate cancer?"

Dr. Booger: "No."

Young fellow: "Great. Because the (world renowned urologist) at (the NCI designated cancer center) told me that exact same thing!"

 

[evilbooyaa]

I get the sentiment, but I think it can be helpful to flip the switch. If your wife or daughter's insurance approved protons for a R sided breast, and it was fully covered for them either way, would you have them get photons?

The issue here isn't that there's no benefit to protons for a R sided breast, it's that there's not enough clinical benefit to justify the higher cost. I'm sure that dosimetrically the plans look better, are more homogeneous, and have better lung sparing

The real question for Jim Urbanic is as follows: if insurance companies DID approve all R sided breast tangents, but they were only willing to pay the equivalent of a photon treatment for it, would you be inundating your cyclotron with R sided breasts? If payments were neutral, the response would be "well there's no proven benefit to protons in this situation, and because it's such a limited resource we reserve it for patients that truly benefit like pediatric patients and some CNS tumors."

Actually whole breast RT with protons seems to have an increased risk of rib fracture (meaning > 0% in published literature) and worse skin toxicity than photon WBI.

Unless someone is treating IMNs or other unique scenarios where lung or heart dosimetry with photon breast RT is higher than published dosimetric constraints, I actually think treating breast cancer with protons is a NEGATIVE based on our current data.

Similar to protons for prostate.

*EDIT* - I have merged this with the Proton Pricing Thread on SDN to save it from the Quagmire that is the Rad Onc Twitter thread.

 

[RSAOaky]

Actually whole breast RT with protons seems to have an increased risk of rib fracture (meaning > 0% in published literature) and worse skin toxicity than photon WBI.

Unless someone is treating IMNs or other unique scenarios where lung or heart dosimetry with photon breast RT is higher than published dosimetric constraints, I actually think treating breast cancer with protons is a NEGATIVE based on our current data.

Similar to protons for prostate. So, the take of James Urbanic, IMO, is a pretty **** one.

Well, I'd like to thank everyone for giving me the data to explain to patients why they shouldn't get a treatment that they're not going to be able to get anyways. Unfortunately most of my patients require transportation to get to treatment or have no idea what the internet even is, so it has yet to come up.

 

[TheWallnerus]

You guys recall "the consensus statement" that came out recently for breast protons? Executive summary: the consensus was that breast proton is good in 100% of cases!

I thought "gee this is neat, I haven't checked the breast proton literature in a while..."

And then I checked one of the cited studies in the consensus statement:

If a breast photon center has results like this, report it to Vladamir Putin for targeting. (Also, don't capitalize "gray.")

 

[RadOncDoc21]

You guys recall "the consensus statement" that came out recently for breast protons? Executive summary: the consensus was that breast proton is good in 100% of cases!

I thought "gee this is neat, I haven't checked the breast proton literature in a while..."

And then I checked one of the cited studies in the consensus statement:

If a breast photon center has results like this, report it to Vladamir Putin for targeting. (Also, don't capitalize "gray.")

Lol, so more side effects but I guess whatevs as long as the big wigs say it’s cool I guess. Nice to also see such a long follow up period of 15 months.