ASTRO 2025

[medgator]

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I hope you are right. I literally just got denied for IMRT for a T3N2 NSCLC and have to go through the appeal process (I don't routinely do lung, but I am covering for a partner at ASTRO).

But my point remains. These companies have no problem looking at hypofrac data and saying "well, longer courses are not better so we will only approve X fractions." Logic would suggest they would be chomping at the bit to stop paying a premium for protons in prostate or H&N, but they are not.

Haven't done a p2p or plan comparison for Stage 3 lung since covid started.

Obnoxious. Most of them know the data from 0617 at this point

 

[TheWallnerus]

I hope you are right. I literally just got denied for IMRT for a T3N2 NSCLC and have to go through the appeal process (I don't routinely do lung, but I am covering for a partner at ASTRO).

But my point remains. These companies have no problem looking at hypofrac data and saying "well, longer courses are not better so we will only approve X fractions." Logic would suggest they would be chomping at the bit to stop paying a premium for protons in prostate or H&N, but they are not.

I’m definitely right about IMRT.

No insurance company guideline allows protons for head and neck. Prostate is mostly allowed due to weird phrasings about IMRT and proton equivalence, but that was because of lawsuit avoidance.

The spend by insurance companies on protons as not as big as one might think. First the payors are very fractured so any individual payor doesn’t see a HUGE rad onc spend in general as is. Second it must not be all rainbows and unicorns as some proton centers clearly don’t do well financially (look at UAB most recently).

 

[OTN]

I don't fully get it either. Maybe they're more afraid of a lawsuit for a proton denial than they are a fraction-issue denial?

Someone correct me if I'm wrong, but I do believe a United Health subsidiary/offshoot owns a stake in the NY Proton Center.

It's for sure lawsuit denial. With our national "experts" willing to blatantly lie on the stand when it comes to proton outcomes, there have been some high-profile lawsuit losses that insurers have had to suffer, so I understand their hesitance to deny.

 

[medgator]

some proton centers clearly don’t do well financially (look at UAB most recently).

Several over the last decade I think. Indiana, Tennessee, plus scuttling of planned centers

 

[Tigerstang]

Several over the last decade I think. Indiana, Tennessee, plus scuttling of planned centers

Delray hanging on by a thread as well

A lot of these are the old mega 250M centers financed with 80% debt

 

[ramsesthenice]

Haven't done a p2p or plan comparison for Stage 3 lung since covid started.

Obnoxious. Most of them know the data from 0617 at this point

Yeah. I recently relocated from the mid west back to the east coast and it is interesting to say the least. Both use evicore but I can easily do things now without request that were unthinkable there and vice versa. So obnoxious. In general, SBRT seems to be more approvable here without appeal but certain definitive IMRT cases and use of IGRT are much more heavily scrutinized.

 

[ramsesthenice]

I’m definitely right about IMRT.

No insurance company guideline allows protons for head and neck. Prostate is mostly allowed due to weird phrasings about IMRT and proton equivalence, but that was because of lawsuit avoidance.

The spend by insurance companies on protons as not as big as one might think. First the payors are very fractured so any individual payor doesn’t see a HUGE rad onc spend in general as is. Second it must not be all rainbows and unicorns as some proton centers clearly don’t do well financially (look at UAB most recently).

How did they fund the trials? They had to be reimbursed for the protons somehow. Did they take IMRT rate? If so, that is not controversial.

 

[radiaterMike]

Some centers have negotiated to bill IMRT rates with local insurers. Some of these centers attract out of network patients, and I'd imagine thier insurers would balk at both proton therapy and out of network coverage.

 

[TheWallnerus]

How did they fund the trials? They had to be reimbursed for the protons somehow. Did they take IMRT rate? If so, that is not controversial.

They get denied and appeal and win some/lose some. Or the insurance plan has a proviso about reimbursing if patient is on an IRB/dot-gov registered trial. Or the patient was on Medicare in an LCD free state. Or they gladly take the 5-10x CMS IMRT rate from a private payer which is 1.5-3x the CMS proton rate. In my opinion, I think it’s not clearly uncontroversial to “underbill” so as to get better than a Medicare rate you would get from regular Medicare. But that can be debated!

 

[NotMattSpraker]

Good post by Sher on Torpedo vs. MDACC:

Yet frames the field's debate as "diametrically opposed"... does anyone actually oppose proton therapy? I don't. I'm not sure how one could.

Sameer's reaction to PartiQoL: "Two great options"

McDonald's reaction to RADCOMP: "High quality care with either photon or proton therapy"

This is nuts and what I oppose. The folks that have made careers "researching" financial toxicity have nothing to say about calling a more expensive therapy that has no additional benefit... high-quality?

I personally do not think we will ever be able to come back to a place of intellectual honesty. Maybe it's not a big deal, maybe it's just me. Extremely disappointing.

 

[communitydoc13]

Proton academic rad onc’s and their admin handlers have private school tuitions and Maybach’s to pay off. Let’s cut them some slack.

I'm very anti-proton for most things. My general take is that you should pay the same for photon/proton and then see where utilization falls, counting on physicians to cultivate real insights regarding toxicity, ease of application, reliability and efficacy.

I'm also not an academic.

But I assure you that radoncs at UPENN, an institution that has gone "all in" on protons regionally (presumably for market share and bottom-line considerations), are not driving Maybachs unless they have other sources of money. In fact, prestige "private groups" with protons don't always pay bank. (The truly private proton centers are completely different).

Admins make what admins make. A radonc admin overseeing a very profitable department is probably on an upward trajectory career wise within the institution.

I am also sure that the profitability of the department matters a lot to the larger institution and impacts the relative status of the radonc department.

This is deeper than just personal finances. This is about ego, it's about institutional investment, it's about preserving the notion that what you have committed your career to is not really of marginal significance (never mind that you may have hurt some patients along the way).

These are all human factors. In fact, we will see some positive trials (when you do enough, some will be positive).

The solution is in the payment. Pay the same and utilization of protons will be what it should be (somewhere between zero and rare).

 

[Gfunk6]

Let's lay our cards on the table.

1. Protons are expensive, really expensive. That expensive must be justfiied by utliization.
2. If you simply use protons where the benefit is clear (e.g. peds, clival chordomas, re-irradiaiton) then you will go bankrupt, hard stop.
3. If you run randomized trials, you always run the risk of the expensive intervention being shown inferior. As such, you run non-inferiority trials instead.
4. Then you can claim:
a) If non-inferiority trial is successful (e.g. protons are equivalent to photons) then mission accomplished
b) if non-inferiorty trial is unsuccessful (e.g. protons are not equivalent) then spin the results. One can simply look at unplanned subset analysis, unplanned clinical endpoints and you will eventually find something with a p of <= 0.05 that you may spin in your favor.

 

[communitydoc13]

2. If you simply use protons where the benefit is clear (e.g. peds, clival chordomas, re-irradiaiton) then you will go bankrupt, hard stop.

This is why there never should have been widespread adoption of protons. They are fine as niche money-losers and research facilities at Harvard and MDACC. They can be a tool at large, dedicated pediatric hospitals (not sure how impressed the peds doctors really are).

Peds is a public service not a money-making service line anywhere.

 

[NotMattSpraker]

This is why there never should have been widespread adoption of protons. They are fine as niche money-losers and research facilities at Harvard and MDACC. They can be a tool at large, dedicated pediatric hospitals (not sure how impressed the peds doctors really are).

Could not agree more. New particles and radiotherapy modalities definitely deserve study. Radiotherapy remains a high value cancer therapy so it's a good investment. Americans pay 11 hospitals extra money to do research for us, do it there and treat for free.

Preprint of the MDACC trial for those that want to read: Phase III Trial of Proton Versus Photon Radiotherapy for Oropharyngeal Cancer