Proton Editorial/Article

[deleted4401]

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JCO this issue has a neat cost analysis of treating intermediate-risk prostate cancer with protons. The editorial comment by Dr. Zietman, although pretentious with the Titanic allegory, is very good. Any thoughts?

www.jco.ascopubs.org/cgi/content/full/25/24/3565

S

 

[Doctor&Geek]

The editorial is linked above. The article with analysis from Konski at Fox Chase is here:

http://jco.ascopubs.org/cgi/content/full/25/24/3603

 

[Brim]

JCO this issue has a neat cost analysis of treating intermediate-risk prostate cancer with protons. The editorial comment by Dr. Zietman, although pretentious with the Titanic allegory, is very good. Any thoughts?

www.jco.ascopubs.org/cgi/content/full/25/24/3565

S

The Titanic allusion is a bit pretentious and overdone, I'll agree, but at least it is understood by the general reading public. This is in contrast to another editorial in the same JCO which gleefully makes use of literary allusion -- "The Sound and the Fury: Financial Conflicts of Interest in Oncology." I don't see what financial conflicts of interest have to do with the Sound and the Fury ... but I've never actually read anything by Faulkner. (As an aside, I find it hilarious that following this article wherein the authors caution about the dangers of conflicts of interest is the standard "conflicts of interest" banner which lists several of the authors' own conflicts of interest. Alrighty then!)

It's also pretentious how Zietman said that he treats prostate cancer with the Massachusetts General Hospital:

"(Note: The author treats prostate cancer with both IMRT and proton beam and the Massachusetts General Hospital and the Francis H. Burr Proton Therapy Center, Boston, MA.)."​

Maybe it was an innocent editing gaffe... or was it?

Anyway, I haven't read the Konski et al article, just the abstract. So I haven't been able to look at their numbers, but intuitively I would think that proton radiotherapy would a lot more expensive than IMRT, more than the 2x figure they deduced.

What struck me was this statement in the conclusion of the Konski article:

"Consideration should be given to limiting the number of proton facilities to allow comprehensive evaluation of this modality."
​

This statement sounds vaguely territorial, not the type of language that would routinely be used in a cost analysis.

 

[Gfunk6]

Very interesting editorial.

I was recently made aware (though I'm sure most residents on this board were already familiar with the concept) of the difference in FDA approval b/w new radiation hardware and new drugs. While the latter have to bear tremendous scrutiny in terms of large-scale Phase I-III trials, the former are considered "medical devices." As such, these "devices" do not have to produce the kind of rigorous evidence required of new medicinal agents.

This is why, in part, that new hardware is pushed through so quickly when it has a "theoretical advantage."

Zietman basically devotes one sentence writing about the need to compare protons w/ photons (w/ the most up-to-date IMRT/IGRT). The fact that he mentions Loma Linda a few sentences before is nearly laughable as they have pretty much become a dedicated proton facility for virtually every cancer type. Larger centers like MGH, MDACC, etc. will never, ever run head-to-head randomized trials comparing protons vs. photons. It simply is not in their financial interest.

Zietman's own study on the subject, published in JCO in 2005 (PMID: 16160131) compares a high vs. low-dose proton boost after photons for prostate CA. RTOG 01-26 is studying basically the same thing, except with photons alone.

Bottom line: As long as protons remain profitable, they will continue to proliferate regardless of the lack of level I evidence. As tech improves and city-block sized cyclotrons are minaturized, I believe even smaller private-practice type places will be able to employ them.