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Aetna loses lawsuit after denying protons

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medgator

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Afaik reading about this, Aetna changed their policy from covering it in adults to mainly covering it for the peds population only while this patient was under coverage

If this wasn't reirradiation, I don't think it was needed, but I'm still happy Aetna had a big verdict against considering the slimy tactics. I believe there were bonuses also given out for denying expensive care
 

RadOncDoc21

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I can actually agree with the use of protons in this situation. I also hate insurance companies and their blanket denials.
 

Palex80

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Protons for nasopharynx certainly make more sense than protons for prostate
 
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oldking

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Protons for nasopharynx certainly make more sense than protons for prostate

First thing that came to my mind ... Don’t see how anybody could disagree with this statement!
 

medgator

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Protons for nasopharynx certainly make more sense than protons for prostate
Agree, but are we not curing NPC with a reasonable morbidity profile currently with imrt?

I'm still glad Aetna lost this one....will make them think twice next time about changing coverage in the middle of a policy and basing performance bonuses on denial of care
 
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ramsesthenice

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Agree, but are we not curing NPC with a reasonable morbidity profile currently with imrt?

I'm still glad Aetna lost this one....will make them think twice next time about changing coverage in the middle of a policy and basing performance bonuses on denial of care

I have to agree with Gator here. My reaction was the same. While protons might certainly have been reasonable, with the information provided it is a difficult to conclude that they would have been absolutely necessary. I am in no way siding with Aetna here, but I have certainly seen my fair share of second opinions where treatment was unnecessarily delayed while physicians were fighting for approval for things that frankly were not needed. I am currently treating someone with a GEJ tumor who got tired of waiting on a big name program in the area to work out the details so they could get the proton therapy that they "so desperately needed." We as a community will be much better equipped to stick it to the most egregious denials when our vocal minority stops lobbing slow pitch softballs down home plate.
 

Palex80

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Agree, but are we not curing NPC with a reasonable morbidity profile currently with imrt?

Probably not or let me rephrase that:

There is probably more room/potential for morbidity reduction by using protons instead of IMRT for nasopharynx than there is by using protons instead of IMRT for prostate.
Wouldn't you agree?

Although IMRT has dramatically improven toxicity in h&n cases, I still find that morbidity is an issue and protons may (it's not evidence based, we still need to do the trials!) decrease morbidity.
 

Palex80

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I have to agree with Gator here. My reaction was the same. While protons might certainly have been reasonable, with the information provided it is a difficult to conclude that they would have been absolutely necessary. I am in no way siding with Aetna here, but I have certainly seen my fair share of second opinions where treatment was unnecessarily delayed while physicians were fighting for approval for things that frankly were not needed. I am currently treating someone with a GEJ tumor who got tired of waiting on a big name program in the area to work out the details so they could get the proton therapy that they "so desperately needed." We as a community will be much better equipped to stick it to the most egregious denials when our vocal minority stops lobbing slow pitch softballs down home plate.
Of course protons are not "absolutely necessary" for nasopharynx. Protons are "absolutely necessary" for only few indications, like chordoma of the skull base.
But they can be highly advantageous in many other cases. Prostate is not one of them...
 

medgator

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Probably not or let me rephrase that:

There is probably more room/potential for morbidity reduction by using protons instead of IMRT for nasopharynx than there is by using protons instead of IMRT for prostate.
Wouldn't you agree?

Although IMRT has dramatically improven toxicity in h&n cases, I still find that morbidity is an issue and protons may (it's not evidence based, we still need to do the trials!) decrease morbidity.
Fair enough. But at 2-3x cost, I won't fault insurers for sticking with imrt until protons are proven superior or the cost goes inline with imrt
 

evilbooyaa

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I mean if it was a T4 nasopharynx and encroaching on her brainstem, then I think protons are not unreasonable.

I don't think this means that every nasopharynx NEEDS protons, but I think there are some situations where it's not unreasonable. H&N with skull base invasion is certainly closer to an 'absolute' indication (like a skull base chordoma) than protons.

I have no qualms about an insurance company losing money due to blanket denials without evaluating the situation. Does this mean that I will be sending all my Nasopharynxes to the nearest proton center? No, but if it's really encroaching on the brainstem and I can't meet dosimetric parameters for brainstem with IMRT without severely underdosing tumor, then yeah, maybe it's worth considering.
 
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RickyScott

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While I am no proponent of protons, I just cant see how any reasonable radiation oncologist could object to their use in this situation. Probably there was a blanket denial that led to this.
 
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ramsesthenice

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While I am no proponent of protons, I just cant see how any reasonable radiation oncologist could object to their use in this situation. Probably there was a blanket denial that led to this.

Cost. Blanket denials are BS and a practice that I wish would die. At the same time, insurance companies are not fundamentally wrong for questioning the need for expensive therapy and evaluating plans on a case-by-case basis. Without knowing the details of the case it is hard to evaluate what a reasonable rad onc would say.
 
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seper

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When a target is right up against a critical structure (brainstem), IMRT is better than protons. Protons would probably spare temporal lobes a bit better (50%-80% IDL area, roughly). Not sure if I'd push protons here.
 

RadRadRad

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Heres my take. Would I mortgage my house to get protons for NPX cancer. Probably not. Would I ask my patient to do the same. Probably not (unless significant invasion towards brainstem I think the benefit is minimal...and even in that scenario we should remember that Toronto is treating chordoma IGIMRT to 74Gy). I hope that this case was encroaching on brainstem and that the insistence on protons was warranted. However would not be surprised if not the case. Ive seen the academic center near me tell patients they have to pay out of pocket for protons for prostate cancer after insurance denial.

All that said the insurance companies should not do blanket denials and case by case analysis is needed
 

Palex80

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When a target is right up against a critical structure (brainstem), IMRT is better than protons. Protons would probably spare temporal lobes a bit better (50%-80% IDL area, roughly). Not sure if I'd push protons here.
Parotids may also be better spared with protons, but that's highly dependent on the N-stage.
 

mikesheree

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If I may ask, is this now the consensus in your field. ? I’m GI path and a tumor board is coming up. So, all things equal, no difference what it will do to the rectum?(with appropriate balloons, spacers, etc.)
 

Gfunk6

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If I may ask, is this now the consensus in your field. ? I’m GI path and a tumor board is coming up. So, all things equal, no difference what it will do to the rectum?(with appropriate balloons, spacers, etc.)

Protons would likely not offer a benefit in terms of survival, toxicity or local control in this scenario. However, it is statically proven to increase your bankruptcy free survival (BFS).


Sent from my iPhone using SDN
 
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medgator

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Protons would likely not offer a benefit in terms of survival, toxicity or local control in this scenario. However, it is statically proven to increase your bankruptcy free survival (BFS).


Sent from my iPhone using SDN
Decrease? Pretty sure no one is more bankruptcy free after going through protons
 
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seper

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Pathophysiology of radiation-induced bowel toxicity in IBD is unknown. It may be related to very small volumes of rectum receiving high doses of radiation, then protons would be worse than IMRT.
 
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ramsesthenice

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If I may ask, is this now the consensus in your field. ? I’m GI path and a tumor board is coming up. So, all things equal, no difference what it will do to the rectum?(with appropriate balloons, spacers, etc.)

The issue is people assume protons are more precise. That’s not actually true on all levels. Protons have better stopping power so you can reduce exit dose (ie, dose delivered past the intended target). Proton centers will show you pretty pictures and they sure look better (and to be clear sometimes they are).

The downside is there is fundamentally more uncertainty with dose deposition with protons than photons. You have to use a slightly higher fudge factor with protons than you do with highly conformal photon IMRT so if the structure you are trying to avoid is right on the target protons won’t help you. You have to have some separation to benefit from protons.
 
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Chartreuse Wombat

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The issue is people assume protons are more precise. That’s not actually true on all levels. Protons have better stopping power so you can reduce exit dose (ie, dose delivered past the intended target). Proton centers will show you pretty pictures and they sure look better (and to be clear sometimes they are).

The downside is there is fundamentally more uncertainty with dose deposition with protons than photons. You have to use a slightly higher fudge factor with protons than you do with highly conformal photon IMRT so if the structure you are trying to avoid is right on the target protons won’t help you. You have to have some separation to benefit from protons.
I prefer the term "precise uncertainty".
 

evilbooyaa

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Here is the consensus (see #4).
EDIT: On the other hand, if you're a "proton practitioner," no consensus at all.

In regards to the second link, I think it's blatantly false advertising (which should be illegal IMO) to make claims like this (in regards to prostate cancer) about protons:

  • Proton patients are almost twice as likely to report treatment had NO IMPACT on their quality of life compared to surgery, conventional radiation, and brachytherapy
  • 4.9% higher overall 5-year survival rate
  • 35% less radiation to bladder and 59% less radiation to the rectum
  • Half as many incidents of long term (2+ years) moderate or severe bowel problems
  • 42% reduction in relative risk of developing a secondary malignancy
  • Significantly fewer reports of gastrointestinal, genitourinary, endocrine, or “other” complications
 
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medgator

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In regards to the second link, I think it's blatantly false advertising (which should be illegal IMO) to make claims like this (in regards to prostate cancer) about protons:

  • Proton patients are almost twice as likely to report treatment had NO IMPACT on their quality of life compared to surgery, conventional radiation, and brachytherapy
  • 4.9% higher overall 5-year survival rate
  • 35% less radiation to bladder and 59% less radiation to the rectum
  • Half as many incidents of long term (2+ years) moderate or severe bowel problems
  • 42% reduction in relative risk of developing a secondary malignancy
  • Significantly fewer reports of gastrointestinal, genitourinary, endocrine, or “other” complications
Wonder why they didn't comment on the financial toxicity between protons, imrt and brachy :laugh: harder to fake that kind of data, I guess
 
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emt409

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Wonder why they didn't comment on the financial toxicity between protons, imrt and brachy :laugh: harder to fake that kind of data, I guess

  • Proton patients are almost 50X as likely to report having to MORTGAGE their house to pay for treatment!
(disclaimer: I made this up, and have no data, but it sounds about right)
 

Radiator20

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Decrease? Pretty sure no one is more bankruptcy free after going through protons

Well, it’s a paradoxical effect: patient BFS decreases, treating center BFS increases. Remarkable!
 

evilbooyaa

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  • Proton patients are almost 50X as likely to report having to MORTGAGE their house to pay for treatment!
(disclaimer: I made this up, and have no data, but it sounds about right)

Sounds like most of the other data on that website. I really wish I could respond by just saying 'citation needed' for all of their outrageous claims.
 

nkmiami

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arent there regulations about medical claims you can make?
 
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