India launches its 2nd proton therapy center

[IonsAreOurFuture]

Mumbai, India is now home to the country's 2nd proton center, and its first publicly-funded facility. 60% of patients will be getting their care paid for by the govt.

Proton therapy comes to public sector now | India News - Times of India

India News: Prime Minister Narendra Modi virtually inaugurated the much-awaited proton beam therapy facility at the Tata Memorial Centre’s Kharghar campus on Thur

timesofindia.indiatimes.com

India's first center, the Apollo Proton Cancer Center, was privately funded, in Chennai on the eastern coast. The article erroneously states that there are 39 operating proton centers globally.

It's actually in now in the 110's, plus 14 carbon ion centers open worldwide.

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[TheWallnerus]

Mumbai, India is now home to the country's 2nd proton center, and its first publicly-funded facility. 60% of patients will be getting their care paid for by the govt.

Proton therapy comes to public sector now | India News - Times of India

India News: Prime Minister Narendra Modi virtually inaugurated the much-awaited proton beam therapy facility at the Tata Memorial Centre’s Kharghar campus on Thur

timesofindia.indiatimes.com

India's first center, the Apollo Proton Cancer Center, was privately funded, in Chennai on the eastern coast. The article erroneously states that there are 39 operating proton centers globally.

It's actually in now in the 110's, plus 14 carbon ion centers open worldwide.

Which proton machine vendor was able to curry favor with the Indian govt for this deal?

 

[medgator]

Which proton machine vendor was able to curry favor with the Indian govt for this deal?

I wonder how much cheaper it was than getting an equivalent machine in the US (pricing isn't the same in all markets for photon Linacs from what I've heard, can't imagine this is any different)

 

[TheWallnerus]

I wonder how much cheaper it was than getting an equivalent machine in the US (pricing isn't the same in all markets for photon Linacs from what I've heard, can't imagine this is any different)

I think almost certainly India got the cheaper deal

 

[FindMeOnTheLinks]

If there was one place I wanted to see build a proton center, it was there. Tata is currently doing the best and most impactful rad onc research of any institution in the world, IMO. Listen to Simul’s podcast about his visit there. I anticipate they will quickly accrue patients on proton studies that would never be done in the US and they will be done the right way as they won’t have the same financial conflicts and red tape that prevents it in the US (at least my hope). This is a very good thing for our field

 

[Tigerstang]

Which proton machine vendor was able to curry favor with the Indian govt for this deal?

curry favor, I see what you did there

 

[deleted1111261]

We used to outsource our unskilled labor to India.

Now we are outsourcing our highest level of medical research - RCTs.

 

[Chartreuse Wombat]

We used to outsource our unskilled labor to India.

Now we are outsourcing our highest level of medical research - RCTs.

Look for medical tourism specific to proton therapy to boom over the next few years.

 

[Fpg1245]

We used to outsource our unskilled labor to India.

Now we are outsourcing our highest level of medical research - RCTs.

I threw my world is flat book in the garbage last week.

 

[deleted1111261]

Look for medical tourism specific to proton therapy to boom over the next few years.

They could 2x as much as they do to their customers and it would be a deal for an American patient.

Bombay is not the easiest place to travel for most of the type of people that would actually do that.

 

[Chartreuse Wombat]

They could 2x as much as they do to their customers and it would be a deal for an American patient.

Bombay is not the easiest place to travel for most of the type of people that would actually do that.

Not the easiest right now but a clever group can facilitate the travel with $$; probably start at 4 times base price and maybe even fly in on a PJ

 

[deleted1111261]

Hahah

just saying, having been there >10 times .. the look westerners have when their eyes are open would cause many to have trust issues with the care. PJ or not, you’re gonna see some terrible stuff. My dad had said he’d never go back in 2016; my mom says the same thing now. Getting American 70 year old person with money to spend 5-6 weeks there.. i presume they are going to build high end hotels near it and make it super easy to never expose yourself to real india May make it easier

 

[sirspamalot]

Close your eyes, hold your nose, and design the experience for medical tourism.

On the other hand: why can't we have floating stabilized platforms in shallow water at the edge (25 miles) of international waters with hovercraft shuttles?

"high seas? protons please!"

 

[Fpg1245]

Hahah

just saying, having been there >10 times .. the look westerners have when their eyes are open would cause many to have trust issues with the care. PJ or not, you’re gonna see some terrible stuff. My dad had said he’d never go back in 2016; my mom says the same thing now. Getting American 70 year old person with money to spend 5-6 weeks there.. i presume they are going to build high end hotels near it and make it super easy to never expose yourself to real india May make it easier

Real India…it’s as real as it gets.

 

[NotMattSpraker]

Hahah

just saying, having been there >10 times .. the look westerners have when their eyes are open would cause many to have trust issues with the care. PJ or not, you’re gonna see some terrible stuff. My dad had said he’d never go back in 2016; my mom says the same thing now. Getting American 70 year old person with money to spend 5-6 weeks there.. i presume they are going to build high end hotels near it and make it super easy to never expose yourself to real india May make it easier

This is a fantastic idea. And we are about to have a glut of expert radiation oncologists we can hire as patient navigators slash tour guides.

The RealSimulD Fellowship in Global Hospitality and Proton Therapy.

 

[Chartreuse Wombat]

This is a fantastic idea. And we are about to have a glut of expert radiation oncologists we can hire as patient navigators slash tour guides.

The RealSimulD Fellowship in Global Hospitality and Proton Therapy.

It may not require several weeks. Tata looking hard at SBRT for prostate (although with protons is scary)

 

[deleted1111261]

Off study, you can definitely pay out of pocket for SBRT. There is a fixed price for 3D or IMRT or SBRT. Presuming same type of schedule for protons.

 

[sirspamalot]

FLASH therapy. It is the beginning of the end. The proton grift will continue for about 10 more years then, like IMRT, it will shuffle off to the back as reimbursement approaches de minimus.

When the aliens visit us they will laugh and point : why did it it take them so long, and how many lives were ruined through financial toxicity or lack of access.

 

[NotMattSpraker]

FLASH therapy. It is the beginning of the end. The proton grift will continue for about 10 more years then, like IMRT, it will shuffle off to the back as reimbursement approaches de minimus.

When the aliens visit us they will laugh and point : why did it it take them so long, and how many lives were ruined through financial toxicity or lack of access.

IMRT does amazing things for so many of my patients. Im not sure Ill ever feel that way about protons.

 

[sirspamalot]

Me neither. But for now.. the slogan is..

"keep the grift alive ... at least until 2025"

 

[IonsAreOurFuture]

Look for medical tourism specific to proton therapy to boom over the next few years.

It's already happening. There are more than one proton centers in my state and patients get bounced from one place to another based on who is "full" or has a waiting list at any given moment.

We also see pts from Texas when MDACC fills up, and a pretty constant stream of inquiries from Canada. Most of these are not candidates or cannot pay out of pocket, but there are a lot of wealthy people in Toronto or Montreal who can and do come to the US for protons and other things.

 

[Fpg1245]

It's already happening. There are more than one proton centers in my state and patients get bounced from one place to another based on who is "full" or has a waiting list at any given moment.

We also see pts from Texas when MDACC fills up, and a pretty constant stream of inquiries from Canada. Most of these are not candidates or cannot pay out of pocket, but there are a lot of wealthy people in Toronto or Montreal who can and do come to the US for protons and other things.

I would assume a lot of Chinese nationals who bought homes in major Canadian cities would have the means to pay out of pocket. Seems like it would be a target audience for places like CC, Mayo, and Anderson

 

[BobbyHeenan]

It's already happening. There are more than one proton centers in my state and patients get bounced from one place to another based on who is "full" or has a waiting list at any given moment.

We also see pts from Texas when MDACC fills up, and a pretty constant stream of inquiries from Canada. Most of these are not candidates or cannot pay out of pocket, but there are a lot of wealthy people in Toronto or Montreal who can and do come to the US for protons and other things.

As it relates to this, if MDACC is following the ASTRO model policy - then pretty much every single patient is "eligible" for protons there, correct?

All it takes is a "registry trial" and per ASTRO it is perfectly appropriate to treat the cervix, lung, esophagus, anal, rectal, pancreas, breast, prostate on protons.

Am I reading it correctly?

https://www.astro.org/uploadedFiles/_MAIN_SITE/Daily_Practice/Reimbursement/Model_Policies/Content_Pieces/ASTROPBTModelPolicy.pdf

 

[sirspamalot]

 

[NotMattSpraker]

As it relates to this, if MDACC is following the ASTRO model policy - then pretty much every single patient is "eligible" for protons there, correct?

All it takes is a "registry trial" and per ASTRO it is perfectly appropriate to treat the cervix, lung, esophagus, anal, rectal, pancreas, breast, prostate on protons.

Am I reading it correctly?

https://www.astro.org/uploadedFiles/_MAIN_SITE/Daily_Practice/Reimbursement/Model_Policies/Content_Pieces/ASTROPBTModelPolicy.pdf

My friend. You are reviewing the old policy. Group 1, or patients who can be treated off trial, has been expanded to include evidence based indications such as:

• Medically inoperable patients with any cancer where you feel "dose escalation" is necessary.
• Any malignant or benign primary bone tumor (lol what)
• IDH wild type GBM
• Advanced pelvic cancers with "significant" pelvic disease
• Patients with a single kidney
• Palliative pediatric cases (this one actually makes me angry)

https://www.astro.org/ASTRO/media/ASTRO/Daily%20Practice/PDFs/ASTROPBTModelPolicy.pdf

 

[deleted1111261]

As it relates to this, if MDACC is following the ASTRO model policy - then pretty much every single patient is "eligible" for protons there, correct?

All it takes is a "registry trial" and per ASTRO it is perfectly appropriate to treat the cervix, lung, esophagus, anal, rectal, pancreas, breast, prostate on protons.

Am I reading it correctly?

https://www.astro.org/uploadedFiles/_MAIN_SITE/Daily_Practice/Reimbursement/Model_Policies/Content_Pieces/ASTROPBTModelPolicy.pdf

Not only are you reading it correctly, but they are adamant that this is the right way to do things. It’s intellectually dishonest and very costly to do it this way. Yes, I have a bias, but 40 years and barely any studies? And the one positive one in adults had to do the summation of toxicities.

Give us clean RCTs!!

 

[Chartreuse Wombat]

Not only are you reading it correctly, but they are adamant that this is the right way to do things. It’s intellectually dishonest and very costly to do it this way. Yes, I have a bias, but 40 years and barely any studies? And the one positive one in adults had to do the summation of toxicities.

Give us clean RCTs!!

“It is difficult to get a (hu)man to understand something, when his their salary depends on not understanding it.”

Modified for more inclusive language from the great Upton Sinclair

 

[NotMattSpraker]

Not only are you reading it correctly, but they are adamant that this is the right way to do things. It’s intellectually dishonest and very costly to do it this way. Yes, I have a bias, but 40 years and barely any studies? And the one positive one in adults had to do the summation of toxicities.

Give us clean RCTs!!

I agree and understand this "negative bias" concept for people that don't have machines, but using that to defend critiques of this policy is more intellectually dishonest than the policy itself!

This policy is insanity. I spoke to an ASTRO staffer about this policy when it dropped. They would not tell me who was on this committee and claimed their lawyers advised anonymity. I used to be on the NCCN. I totally understand the stakes here and the concerns for lobbying. They published our names and just asked to sign an NDA. It worked great; pharma could not (directly) lobby us and no one went to hospital jail. Weird! Of course, this staffer had no answer for that other than deferring to their "lawyer".

The way ASTRO seems to do all of their high stakes policy stuff in secret... such a cowardly and gross way to operate. The people that worked on this should be ashamed of themselves.

 

[TheWallnerus]

I agree and understand this "negative bias" concept for people that don't have machines, but using that to defend critiques of this policy is more intellectually dishonest than the policy itself!

This policy is insanity. I spoke to an ASTRO staffer about this policy when it dropped. They would not tell me who was on this committee and claimed their lawyers advised anonymity. I used to be on the NCCN. I totally understand the stakes here and the concerns for lobbying. They published our names and just asked to sign an NDA. It worked great; pharma could not (directly) lobby us and no one went to hospital jail. Weird! Of course, this staffer had no answer for that other than deferring to their "lawyer".

The way ASTRO seems to do all of their high stakes policy stuff in secret... such a cowardly and gross way to operate. The people that worked on this should be ashamed of themselves.

"Something something something our lawyers. Something something. Lawyers something something."

- ASTRO, when asked reasonable questions

 

[communitydoc13]

Medically inoperable patients with any cancer where you feel "dose escalation" is necessary.

This is the most absurd one in my mind.

I remember being introduced to protons and the 1D dose curve and the idea that they would be a tool for dose escalation.

However, dose uncertainty is so much higher and range uncertainty mandates expanded target volumes. Protons are not a tool for dose escalation.

If you want to reduce the second malignancy risk by 1% in a young person with lymphoma, fine. Doses are low enough that you are probably not going to hurt someone with protons.

 

[evilbooyaa]

My friend. You are reviewing the old policy. Group 1, or patients who can be treated off trial, has been expanded to include evidence based indications such as:

• Medically inoperable patients with any cancer where you feel "dose escalation" is necessary.
• Any malignant or benign primary bone tumor (lol what)
• IDH wild type GBM
• Advanced pelvic cancers with "significant" pelvic disease
• Patients with a single kidney
• Palliative pediatric cases (this one actually makes me angry)

https://www.astro.org/ASTRO/media/ASTRO/Daily%20Practice/PDFs/ASTROPBTModelPolicy.pdf

[citation needed]
I mean for pretty much the ENTIRE proton policy.

Like, this is the **** that makes the government not take us (as a field) seriously.

 

[BobbyHeenan]

The policy is basically "every curative intent cancer is good for protons as long as on a registry trial."

We (the field) will pick through the design and endpoints and stats and p-values of every trial with a fine tooth comb.

But does no one at ASTRO have the intellectual honesty to say "but a registry trial adds nothing to the literature about whether proton therapy is better, worse, or the same as photon therapy for common cancers?"

 

[BobbyHeenan]

At this point
As a policy measure
Astro should say “you get paid 3D unless you are in a prospective comparative study”

I would support IMRT rates for common cancers (that should have plenty of chance to enroll/randomize), pay proton rates if on the trial.

For rare cancers a registry trial is fine...but a registry trial for prostate, breast, lung, esophagus does absolutely nothing to move the clinical data forward. We would have already seen a signal if the treatment is CLEARLY way worse or way better. Nothing short of randomization will solve it. ....and good luck enrolling if the health plan just auto-auth's it for proton. EVery patient is going to pick protons off study.

What a mess of a policy statement.

 

[NotMattSpraker]

I would support IMRT rates for common cancers (that should have plenty of chance to enroll/randomize), pay proton rates if on the trial.

For rare cancers a registry trial is fine...but a registry trial for prostate, breast, lung, esophagus does absolutely nothing to move the clinical data forward. We would have already seen a signal if the treatment is CLEARLY way worse or way better. Nothing short of randomization will solve it. ....and good luck enrolling if the health plan just auto-auth's it for proton. EVery patient is going to pick protons off study.

What a mess of a policy statement.

This thread is loaded with great ideas and comments.

Hey ASTRO, maybe next time you can take a more honest approach and invite radiation oncologists to comment before it’s published.

 

[medgator]

This thread is loaded with great ideas and comments.

Hey ASTRO, maybe next time you can take a more honest approach and invite radiation oncologists to comment before it’s published.

#DefundASTRO

 

[BobbyHeenan]

This thread is loaded with great ideas and comments.

Hey ASTRO, maybe next time you can take a more honest approach and invite radiation oncologists to comment before it’s published.

There really should have been a comment period. They do that for guidelines and other stuff but completely bypassed it here.

 

[IonsAreOurFuture]

I would support IMRT rates for common cancers (that should have plenty of chance to enroll/randomize), pay proton rates if on the trial.

For rare cancers a registry trial is fine...but a registry trial for prostate, breast, lung, esophagus does absolutely nothing to move the clinical data forward. We would have already seen a signal if the treatment is CLEARLY way worse or way better. Nothing short of randomization will solve it. ....and good luck enrolling if the health plan just auto-auth's it for proton. EVery patient is going to pick protons off study.

What a mess of a policy statement.

There are certainly centers that are willing to accept IMRT rates for protons. In the end though, I think that is a somewhat dishonest and unsustainable approach, in that the insurance company is getting something for nothing. It reminds me of when they are willing to "give" you 10 fractions of 3DCRT "today" if you'll drop your request for IMRT. In theory you could still treat the patient with IMRT, but I think most hospital billing departments would frown on billing for something other than what was provided.

I practice in Flint, Michigan. Our payers will generally allow proton rates for protons and IMRT rates for IMRT. Proton SBRT is an exception (pays same as Xray SBRT), but that's about it. YMMV

The proposal to let patients on a trial get proton rates is a very good one, but it requires the insurance company to acknowledge that they need to pay for research. Oftentimes I get the same response on or off trial. Basically they won't authorize protons even on a trial, due to "lack of evidence," which is a bit of a Catch 22, and they know it. Those insurance companies sure are clever.

 

[BobbyHeenan]

There are certainly centers that are willing to accept IMRT rates for protons. In the end though, I think that is a somewhat dishonest and unsustainable approach, in that the insurance company is getting something for nothing. It reminds me of when they are willing to "give" you 10 fractions of 3DCRT "today" if you'll drop your request for IMRT. In theory you could still treat the patient with IMRT, but I think most hospital billing departments would frown on billing for something other than what was provided.

I practice in Flint, Michigan. Our payers will generally allow proton rates for protons and IMRT rates for IMRT. Proton SBRT is an exception (pays same as Xray SBRT), but that's about it. YMMV

The proposal to let patients on a trial get proton rates is a very good one, but it requires the insurance company to acknowledge that they need to pay for research. Oftentimes I get the same response on or off trial. Basically they won't authorize protons even on a trial, due to "lack of evidence," which is a bit of a Catch 22, and they know it. Those insurance guys sure are clever.

Insurance and even vendors need to be buying in/supporting trials. ASTRO should be all over this and pushing this hard. Instead you get this registry trial crap and blanket "just treat everyone with protons"....of course insurance will push back.

It's such a mess.

Tin foil hat again:
Institutions don't *really* want to see what a randomized trial shows, and insurance doesn't either...but for different reasons.

 

[thecarbonionangle]

truths/veritas:

1) insurances don’t want to pay for patients to be on studies
2) insurances dont want to pay for patients because there are no studies
3) device makers have not stepped up to fund studies in a large degree (outside of the two varian FLASH, and varian exited PT)
4) insurance companies do not want a bunch of positive studies
5) many people on this board, and in our field do not want positive studies because it threatens their bottomline
6) people in these centres do not want negative studies because it threatens bottomline

Will the Indians save us and enlighten us on how and when to use this? Maybe. If you think India is bereft of grift, i got a bridge to sell ya! Enjoy your biryani folks

 

[grenz]

truths/veritas:

1) insurances don’t want to pay for patients to be on studies
2) insurances dont want to pay for patients because there are no studies
3) device makers have not stepped up to fund studies in a large degree (outside of the two varian FLASH, and varian exited PT)
4) insurance companies do not want a bunch of positive studies
5) many people on this board, and in our field do not want positive studies because it threatens their bottomline
6) people in these centres do not want negative studies because it threatens bottomline

Will the Indians save us and enlighten us on how and when to use this? Maybe. If you think India is bereft of grift, i got a bridge to sell ya! Enjoy your biryani folks

It’ll be the UK that provides us the evidence on protons. They have a knack for enrolling on trials that the US cannot, and no profit incentive since it’s all publicly owned.

 

[NotMattSpraker]

There really should have been a comment period. They do that for guidelines and other stuff but completely bypassed it here.

Yes exactly. That makes it so much worse in my mind. Open comment that low level guidelines that have little economic impact but develop your proton payer policy in secret. Nice.

My phone call with the staffer devolved in to me screaming at them because it became clear these people have no integrity. They can't even be honest with themselves.

FWIW, this person told me they are currently updating the IMRT payer policy and there is no plan for pre-publication member comment. Can't wait.

ASTRO is trash.

 

[sirspamalot]

Well, if you need more indications to treat to keep that linac humming.. beyond the usuals.. and seeing as you ain't gonna get many OA referrals.. how about:

Preliminary efficacy and safety analysis: 12-month results in 83 patients using a novel approach of widefield radiation therapy for extensive skin field cancerization with or without keratinocyte cancers - PubMed

Registry data demonstrate the potential for widefield RT to treat patients with significant skin pathology who have exhausted other therapies and require durable, minimally invasive treatment options. At 12 months, observed clinical success rates were higher than those reported for topical...

pubmed.ncbi.nlm.nih.gov

 

[IonsAreOurFuture]

It’ll be the UK that provides us the evidence on protons. They have a knack for enrolling on trials that the US cannot, and no profit incentive since it’s all publicly owned.

They have a left sided breast cancer trial enrolling now.

If it's positive, they will have to triple their capacity for those patients alone.

 

[medgator]

They have a left sided breast cancer trial enrolling now.

If it's positive, they will have to triple their capacity for those patients alone.

And if it isn't they weren't as stupid as we were with building capacity.

Probably better to have the data before shelling out 5-20x the cost of a well-equipped photon vmat/srt accelerator

 

[deleted1111261]

There are certainly centers that are willing to accept IMRT rates for protons. In the end though, I think that is a somewhat dishonest and unsustainable approach, in that the insurance company is getting something for nothing. It reminds me of when they are willing to "give" you 10 fractions of 3DCRT "today" if you'll drop your request for IMRT. In theory you could still treat the patient with IMRT, but I think most hospital billing departments would frown on billing for something other than what was provided.

I practice in Flint, Michigan. Our payers will generally allow proton rates for protons and IMRT rates for IMRT. Proton SBRT is an exception (pays same as Xray SBRT), but that's about it. YMMV

The proposal to let patients on a trial get proton rates is a very good one, but it requires the insurance company to acknowledge that they need to pay for research. Oftentimes I get the same response on or off trial. Basically they won't authorize protons even on a trial, due to "lack of evidence," which is a bit of a Catch 22, and they know it. Those insurance companies sure are clever.

So, I don’t think we’ve met but a patient of mine wanted a proton opinion and our patients tend to prefer driving to Flint rather than Detroit suburbs. Sent him to Flint. He claimed that he was told it had to be conventional fx, that the 5 fx I had recommended was not possible. So he came back to me.

 

[TheWallnerus]

They have a left sided breast cancer trial enrolling now.

If it's positive, they will have to triple their capacity for those patients alone.

Positive for what?!

 

[taserlaser]

Positive for what?!

I thought protons were pretty positive already. Electrons on the other hand…

edit:stupid autocorrect said elections lol

 

[thecarbonionangle]

Positive for what?!

“Rib fractures” zing!!!

 

[deleted1111261]

The online world is just more complete when carbon is present ❤️❤️ More morning chuckles for me!

 

[TheWallnerus]

I thought protons were pretty positive already. Elections on the other hand…

Elections!