Proton Therapy at UTSW

[StudentRadOnc]

Just heard that UTSW is getting protons - FYI

http://www.utsouthwestern.edu/newsroom/news-releases/year-2012/july/proton-therapy-choy.html

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[Gfunk6]

"The precision of the proton beam allows for unprecedented focus and intensity in especially hard-to-reach places that tend to characterize head and neck cancers – and in pediatric cancers, where access can be anatomically much tighter," said Hak Choy, M.D., Chairman of Radiation Oncology at UT Southwestern.

I'm guessing mostly prostate cancer but that's just because I'm a cynical bastard. 😉

 

[Charles_Carmichael]

Man, UTSW's getting some cool toys lately. They got one of those Vero SBRT machines 1.5 years ago and now, protons?

 

[neo87]

haha proton centers are popping up everywhere.The random community hospital I'm doing my TY at is getting one, and so is the random community hospital affiliated with my bro's residency program...crazy waste

 

[napoleondynamite]

I'm guessing mostly prostate cancer but that's just because I'm a cynical bastard. 😉

 

[Charles_Carmichael]

And we wonder why Medicare is coming after us? Seems like it would have been in all of Radiation Oncologys best interest to find a way to share these centers and put 1-2 per region. Now it seems like everyone is talking about getting protons. Until we can get the cost of these systems down to the point that the costs allow for billing in line with linacs, this shouldn't be happening.

+ infinity!

MDACC has protons. I don't see why UTSW also needs them, when they're in the same state (though I realize that Texas is a big state). I fully support the idea of having 1-2 per region and having true proton cases referred to them rather than opening new proton centers all over the place.

 

[temujim]

If we are to choose where CMS puts it dollars, is it not better that it funds radiation, in whatever form? After all, radiation, whether it be protons or photons has the potential to cure cancer. This is the argument that many national health services make when declining to fund the latest targeted therapy. For example, no bevacizumab for a certain indication = X number more RT centers.

In any case, to whom is CMS accountable? Certainly not patients.

And we wonder why Medicare is coming after us? Seems like it would have been in all of Radiation Oncologys best interest to find a way to share these centers and put 1-2 per region. Now it seems like everyone is talking about getting protons. Until we can get the cost of these systems down to the point that the costs allow for billing in line with linacs, this shouldn't be happening.

 

[medgator]

Sad but true. From an epidemilogical standpoint, it's irrational to need this many proton centers around the country to treat "pediatric" patients and weird CNS/spine tumors

 

[jaharmy]

But in all fairness, UTSW is on the way up and is truly stellar in research - 5 Nobel prizes winners and counting. DFW is the third largest metroplex in the country and 4 hrs away from Houston. Nobody questions philly and nyc having protons. UTSW seems like a perfect place for protons to me. I'm just saying...

 

[RadRadRad]

I'm not sure the number of nobel prize winners is relevant. If the goal of a proton center is to treat pediatric and certain head/neck/CNS tumor with radiotherapy, I would like to see the center being run by an institution with particular clinical expertise in treating these malignancies (and sufficient volume to justify their existence). St. Jude only treats pediatrics and still does not have a proton center (although one is in the works).

 

[Werg]

And Oklahoma City (3.5 hours from Dallas) will have its 2nd proton therapy facility complete before UTSW gets theirs...

 

[deleted4401]

Why does CMS/Medicare reimburse any more for protons than IMRT for prostate cancer? The people who run that organization are world-class stupid. I know calling people names is not a great way to argue, but the colossal lack of intelligence on their part is mind-boggling. If they want to stop the proliferation of proton centers, they'd let the centers charge whatever they want and reimburse as for IMRT, or hell, 3D. The only patients with prostate cancer treated with protons that should get higher reimbursement would be on randomized trials comparing it to IMRT. Let's see how many people would be interested in putting 2 proton centers in Oklahoma City, then ... Philly has one and Baltimore is getting one, while located less than 2 hours away. Suburban Detroit is getting one, while there are centers in suburban Chicago and Indianapolis, already.

I'm just stunned at this 15% rate cut. Where do they come up with this nonsense? Does anyone have the language of what changes they have made for SBRT and IMRT? Is it tech only or professional, too? I'm all for selflessness, as the pot is smaller and we're going bankrupt, but why target such a small piece of the pie, while allowing proton centers to bill $100k per case and allow other specialists to continue to gouge the insurance companies?

All the hatred/venom/spite directed towards the President/Obamacare should be aimed towards CMS/Medicare. They have been the real devil for years, with the SGR formula, the arbitrary calculation of usual & customary fees, and the targeted cuts to specific specialties. And while I'm ranting, let me tell you that I'm certain that a large portion of these recent actions have come because of the series of New York Times articles AND their most recent physician salary survey. There is no other reason that our specialty would get the highest cuts - more than double any other provider - without that media hit job. I don't even want to read their Sunday Styles section any more, just makes me sick to my stomach.

-S

 

[jaharmy]

The reference to nobel prize winners was just meant as a simple measuring stick. The point is UTSW has BOTH great research and clinical departments (top 10 children's hospital). And again, the DFW area has suburbs larger than Memphis. It should be about where the cancer center can help the most patients.

 

[Palex80]

 

[Gfunk6]

Everyone who builds a proton center does the requisite song and dance about pediatric and skull base cancers. However, regardless of how many Nobel prize winners they have, nobody can afford the financing for a proton center by only treating appropriately.

Prostate cancer patients pay the bills. Also, no new proton centers will do a randomized trial with photons. If the results are equivalent, then the entire house of cards comes tumbling down which is a pretty big disincentive.

In the end, it's all about riding the gravy train until you run out of tracks.

 

[Radonc11]

If they want to stop the proliferation of proton centers, they'd let the centers charge whatever they want and reimburse as for IMRT, or hell, 3D.

Proton reimbursement =IMRT reimbursement is exactly what needs to happen! End the arms race!

 

[medgator]

Proton reimbursement =IMRT reimbursement is exactly what needs to happen! End the arms race!

Considering the recent SEER data, Protons should reimburse less for prostate CA

 

[OTN]

UTSW will be the third proton center in Texas, behind MDA (open) and Baylor/Texas Oncology:

http://media.baylorhealth.com/chann...ns-in-talks-to-bring-proton-therapy-to-region

 

[StudentRadOnc]

I think we could be losing sight of the big picture here. We are very fortunate to be in this field. Whatever costs we may feel we are faced with, we cannot forget about the costs that many cancer patients face. Not just for treatment, but for food/room/board in a new city if long-term treatments are required. And that's not even addressing the costs endured by the caretakers. Sure, not everything is known about the utility of proton therapy, but one cannot help to think that the only way to know is to train the best doctors on all the equipment that our field has to offer.

 

[ToasterThief]

I think we could be losing sight of the big picture here. We are very fortunate to be in this field. Whatever costs we may feel we are faced with, we cannot forget about the costs that many cancer patients face. Not just for treatment, but for food/room/board in a new city if long-term treatments are required. And that's not even addressing the costs endured by the caretakers. Sure, not everything is known about the utility of proton therapy, but one cannot help to think that the only way to know is to train the best doctors on all the equipment that our field has to offer.

My bet is that it'd be cheaper to keep 5 proton centers in the country and simply pay for room/board for the few thousand cases that might benefit each year.

 

[Palex80]

I think we could be losing sight of the big picture here. We are very fortunate to be in this field. Whatever costs we may feel we are faced with, we cannot forget about the costs that many cancer patients face. Not just for treatment, but for food/room/board in a new city if long-term treatments are required. And that's not even addressing the costs endured by the caretakers. Sure, not everything is known about the utility of proton therapy, but one cannot help to think that the only way to know is to train the best doctors on all the equipment that our field has to offer.

On the other hand, allow me to question the quality of treatment delivered to the indicidual patient, if instead of a few dedicated centers treating challenging rare diseases (giving 74 Gy for a skull base chordoma without hurting temporal lobes, chiasma and Nn. opticii is not trivial), this "privilege" is given to multiple centers.

I wouldn't like to be treated in a proton center whose patient load is mainly composed of prostate cancer and only treats 5 chordomas per year. I'd rather go to a specialized center, treating 50 chordomas per year, even if this means travelling further and staying somewhere away from home.

 

[StudentRadOnc]

On the other hand, allow me to question the quality of treatment delivered to the indicidual patient, if instead of a few dedicated centers treating challenging rare diseases (giving 74 Gy for a skull base chordoma without hurting temporal lobes, chiasma and Nn. opticii is not trivial), this "privilege" is given to multiple centers.

I wouldn't like to be treated in a proton center whose patient load is mainly composed of prostate cancer and only treats 5 chordomas per year. I'd rather go to a specialized center, treating 50 chordomas per year, even if this means travelling further and staying somewhere away from home.

Point taken. But how did the "specialized centers" become so specialized in the first place? Was it because patients had no choice in where they could go to seek treatment and thus the majority of the cases traveled far and wide to go to one center? How do we know that those centers that only treated 5 chordomas could not quickly become experts in their field? To me, again, it's about the big picture. The better trained we are, the better our field, and the better care we can offer patients.

 

[StudentRadOnc]

I don't know if you're a resident at UTSW or what but your defense is pretty weak. Those institutions that started with protons earlier are obviously going to be more experienced treating rare cases with protons and as such the distance patients travel is worth it. As a resident, I sent many patients to proton centers some distance away because it was the right thing to do and the familys could either afford for the indirect costs or we and the proton center found a way to take care of those costs so that excuse is pretty weak in my opinion. As for increasing the number of experts, do we really need more than a handful of experts in disease sites with such low numbers to start with?

This has nothing to do with UTSW, which is a great program, with top flight attendings, research, and technology. It's the question of what the true value of protons are and at this time the only real evidenced based value I can find is for pediatrics, BOS tumors, and re-treats with a few others thrown in (ex. uveal melanoma). For the incidence of those cases does the state of Texas need that many proton centers? Absolutely not. Sure it would be nice if a parent with a pediatric cancer could take their kid down the block for protons. Problem is that $100 million dollar plus toy needs to financed and so either we treat appropriately and limit the number centers or we expand our rationale for treating with protons without evidence at an excessive cost to society. sounds like you're comfortable with the latter. Me, not so much.

My point has nothing to do with UTSW and believe it or not I'm not actually taking a side in the deservedness of UTSW and their proton center. So to call anything I said "weak" shows that you totally missed my point. Cancer patients are ill and to so flippantly say that I'll send them off to xyz center shows that you truly don't empathize with them or understand how onerous a burden travel is for sick patients.

 

[jaharmy]

My point has nothing to do with UTSW and believe it or not I'm not actually taking a side in the deservedness of UTSW and their proton center. So to call anything I said "weak" shows that you totally missed my point. Cancer patients are ill and to so flippantly say that I'll send them off to xyz center shows that you truly don't empathize with them or understand how onerous a burden travel is for sick patients.

Couldn't have said it better! Cancer patients are sick. It's hard for them to walk up a flight of stairs much less get on a plane and fly across the country. It's hard to believe that we as future-doctors / doctors are arguing about having too many treatment options. Let's stop thinking about our pocketbooks and realize that there are people in need out there.

 

[medgator]

My point has nothing to do with UTSW and believe it or not I'm not actually taking a side in the deservedness of UTSW and their proton center. So to call anything I said "weak" shows that you totally missed my point. Cancer patients are ill and to so flippantly say that I'll send them off to xyz center shows that you truly don't empathize with them or understand how onerous a burden travel is for sick patients.

Couldn't have said it better! Cancer patients are sick. It's hard for them to walk up a flight of stairs much less get on a plane and fly across the country. It's hard to believe that we as future-doctors / doctors are arguing about having too many treatment options. Let's stop thinking about our pocketbooks and realize that there are people in need out there.

Sounds great in an ideal world. Unfortunately here in the real world, cost control is becoming the issue of the day/week/month/year/decade etc. Health care resources are not infinite and proton therapy is incredibly expensive compared to standard linac-based radiation therapy, without the necessary data to prove such costs are warranted outside of very select indications.

How do you feel about pitting that cancer patient's care against other deserving causes such as vacciniation/prevention that can nip healthcare problems in the beginning.for countless numbers of individuals?

This chart may help you understand things a bit better.

 

[Gfunk6]

Just heard that UTSW is getting protons - FYI

http://www.utsouthwestern.edu/newsroom/news-releases/year-2012/july/proton-therapy-choy.html

I'm sorry OP. I'm guessing you are a junior resident at UTSW who wanted to share this good news. Sadly the timing of your post with recent proposed Medicare cuts was unforunate. Instead of sharing your joy, we used cyclotron construction as an example of the wretched excesses of healthcare spending.

SDN can be a harsh mistress. 😀

 

[napoleondynamite]

Why does CMS/Medicare reimburse any more for protons than IMRT for prostate cancer? The people who run that organization are world-class stupid. I know calling people names is not a great way to argue, but the colossal lack of intelligence on their part is mind-boggling. If they want to stop the proliferation of proton centers, they'd let the centers charge whatever they want and reimburse as for IMRT, or hell, 3D. The only patients with prostate cancer treated with protons that should get higher reimbursement would be on randomized trials comparing it to IMRT. Let's see how many people would be interested in putting 2 proton centers in Oklahoma City, then ... Philly has one and Baltimore is getting one, while located less than 2 hours away. Suburban Detroit is getting one, while there are centers in suburban Chicago and Indianapolis, already.

I'm just stunned at this 15% rate cut. Where do they come up with this nonsense? Does anyone have the language of what changes they have made for SBRT and IMRT? Is it tech only or professional, too? I'm all for selflessness, as the pot is smaller and we're going bankrupt, but why target such a small piece of the pie, while allowing proton centers to bill $100k per case and allow other specialists to continue to gouge the insurance companies?

All the hatred/venom/spite directed towards the President/Obamacare should be aimed towards CMS/Medicare. They have been the real devil for years, with the SGR formula, the arbitrary calculation of usual & customary fees, and the targeted cuts to specific specialties. And while I'm ranting, let me tell you that I'm certain that a large portion of these recent actions have come because of the series of New York Times articles AND their most recent physician salary survey. There is no other reason that our specialty would get the highest cuts - more than double any other provider - without that media hit job. I don't even want to read their Sunday Styles section any more, just makes me sick to my stomach.

-S

👍

Well said

 

[napoleondynamite]

And we wonder why Medicare is coming after us? Seems like it would have been in all of Radiation Oncologys best interest to find a way to share these centers and put 1-2 per region. Now it seems like everyone is talking about getting protons. Until we can get the cost of these systems down to the point that the costs allow for billing in line with linacs, this shouldn't be happening.

This is precisely the problem though. While I wholeheartedly reject the idea that so many proton centers are popping up, I support the right of each individual center to build one if they choose. Naturally each center wants to maintain competetiveness. Who would decide which institution is granted the prestige and technology if only a certain number were "allowed?"

Unfortunately for our field, the only way to resolve this will be to slash reimbursement and cut the carrot in smaller pieces..which will affect all technology, not just protons. We have become just plain irresponsible, and frankly, dishonest as a field in the marketing of these technologies.

Certainly there is a role for protons. However, the reimbursement is actually hindering real science from exploring that role. If I ran a lemonade stand and you would pay me $40 for a cup of lemonade but only $4 for a bottle of water, am I goimg to offer to flip a coin to decide which you should drink? OK, dumb example, but you get my drift.

 

[bix]

Why does CMS/Medicare reimburse any more for protons than IMRT for prostate cancer? The people who run that organization are world-class stupid.
-S

Some of how pricing for different procedures gets set is through the RUC (Relative Value Update Committe) which is an AMA committee in an advisory role to the CMS. The CMS usually takes the RUC's recommendation and private insurers follow suite. Below is an article on the RUC (they got info from former RUC members but not the AMA or current members). There are plenty of other articles out there on the RUC. But, a small group of doctors have a lot of say in the pricing of medical procedures.

http://www.marketplace.org/topics/life/health-care/secret-world-health-care-pricing

 

[Radonc11]

Does San Diego really need two proton centers with investments nearing half a billion dollars? Private investors don't care about Bragg Peak! They only see dollars!

If there was any doubt about why there is so much anger about Protons for prostate, UCSD vs Scripps proton megawar should be clear evidence! Its an armsrace and the guy with bigger guns might just win out.

This has nothing to do with options for patients or empathy. It is about dollars and cents.

If protons where reimbursed the same as prostate IMRT (or less) there would be no cyclotron at scripps. Not to mention Hampton, UCSD etc.

At my current count, there are 17 total (operational, in development or underconstruction) proton sites in the US. If the current reimbursement rates (which increased 2 years in a row) continue to produce 100K treatments for prostate...well your guess is as good as mine.

 

[napoleondynamite]

In light of that SEER publication, does anyone predict NCCN would be brave enough to give recommendations about appropriate choices of RT modalities in prostate ca? Can you imagine if protons were category 2B - what would the radio and TV ads say then?

 

[StudentRadOnc]

I'm sorry OP. I'm guessing you are a junior resident at UTSW who wanted to share this good news. Sadly the timing of your post with recent proposed Medicare cuts was unforunate. Instead of sharing your joy, we used cyclotron construction as an example of the wretched excesses of healthcare spending.

SDN can be a harsh mistress. 😀

Thanks gfunk. I'm not a resident there but my father is on faculty and I am familiar with the school and dfw area. I do agree that the timing of the post was unfortunate and did spark a heated debate that had more to do with today's politics and financial woe than I expected. I appreciate the debate points (and graphical testimony) but I'm neither trying to convince anyone of anything nor am I trying to be convinced. I have the opinion that good cities with good programs should have proton centers. I think these programs should be chosen based on geographical/population density and quality of institution so that the appropriate research can go along with/test treatment utility. I see a need in Dallas. Do I see a need in every community hospital in the surrounding metroplex? No.

 

[Palex80]

Point taken. But how did the "specialized centers" become so specialized in the first place? Was it because patients had no choice in where they could go to seek treatment and thus the majority of the cases traveled far and wide to go to one center? How do we know that those centers that only treated 5 chordomas could not quickly become experts in their field? To me, again, it's about the big picture. The better trained we are, the better our field, and the better care we can offer patients.

You will never be an "expert" in chordomas, if you treat only 5 of them per year. It's as simple as that. This is nothing strange or unknown in the world of medicine. Look at surgery:
Every surgeon can perform an appendectomy, but there are some very special procedures (for example in neurosurgery or thoracic/heart surgery), which are only performed by few people around the US (or even the world).

It's as simple as that.


If a close friend of yours from Texas developed a chordoma in 8 years from now and asked you, where he should go for treatment, what would you tell him?
1. "Go to the new Texas proton facility around the corner!", knowing, that they usually treat 4-5 cases/year?
2. "Go to Boston!", knowing, that they have treated hundreds of patients there and have generated most of the data, on which treatment of chordomas is based upon.

If my girlfriend developed a chordoma in 8 years from now and we lived in Italy, I would not send her to the new proton facility in Trento (which should be operational by then). I would do my best to get her spot in the PSI (Paul Scherrer Institute), Switzerland.


Currently, I can see wide-spread use of protons only meaningful for children.
Children in most cases have a clear indication for protons and I have referred over 50% of the kids, I've seen, to protons with good results.
The other clear indications are chordomas/chondrosarcomas of the skull base, spine and pelvis. But these tumors are so rare, that you only need a handful of centers to cover the demand. Adenoidcystic carcinomas or some crazy sarcomas of the head/pelvis can also be a good indication, but these tumors are also very rare.
All other proton indications are subject of clinical research. I do believe, that some patients would profit from protons (for example Hodgkins disease or seminoma), but will not refer patients to protons for these indications outside of a clinical trial. Prostate is total no-go in my opinion and waste of resources. Actually is not even a "waste" of resources. It's a misuse of resources, one that prohibits another patient from getting a treatment, which would make a clinical difference for him.

 

[StudentRadOnc]

You will never be an "expert" in chordomas, if you treat only 5 of them per year. It's as simple as that. This is nothing strange or unknown in the world of medicine. Look at surgery:
Every surgeon can perform an appendectomy, but there are some very special procedures (for example in neurosurgery or thoracic/heart surgery), which are only performed by few people around the US (or even the world).

It's as simple as that.


If a close friend of yours from Texas developed a chordoma in 8 years from now and asked you, where he should go for treatment, what would you tell him?
1. "Go to the new Texas proton facility around the corner!", knowing, that they usually treat 4-5 cases/year?
2. "Go to Boston!", knowing, that they have treated hundreds of patients there and have generated most of the data, on which treatment of chordomas is based upon.

If my girlfriend developed a chordoma in 8 years from now and we lived in Italy, I would not send her to the new proton facility in Trento (which should be operational by then). I would do my best to get her spot in the PSI (Paul Scherrer Institute), Switzerland.


Currently, I can see wide-spread use of protons only meaningful for children.
Children in most cases have a clear indication for protons and I have referred over 50% of the kids, I've seen, to protons with good results.
The other clear indications are chordomas/chondrosarcomas of the skull base, spine and pelvis. But these tumors are so rare, that you only need a handful of centers to cover the demand. Adenoidcystic carcinomas or some crazy sarcomas of the head/pelvis can also be a good indication, but these tumors are also very rare.
All other proton indications are subject of clinical research. I do believe, that some patients would profit from protons (for example Hodgkins disease or seminoma), but will not refer patients to protons for these indications outside of a clinical trial. Prostate is total no-go in my opinion and waste of resources. Actually is not even a "waste" of resources. It's a misuse of resources, one that prohibits another patient from getting a treatment, which would make a clinical difference for him.

OR my friend gets sick and I say "Hey, why don't you go to the new Texas facility which is newer and is run by the former proton specialist from Boston".

Just an example but you forget that faculty move locations. There was a time MD Anderson was just an empty grass lot and now it's a mini Harvard satellite program with all the Boston transplants.

I think it may be time to move this discussion to a different thread so that you guys can continue to argue the validity of protons because that was certainly NOT the point of the original post.

 

[Palex80]

One person does not make "expertise", especially not in the world of protons.
It takes a whole team to run a place like that, I've experienced that myself, having worked in a proton facility for some time.

You need the physics, you need the doctors, you need the cooperating surgeons, you need lots of stuff to perform such a complex treatment as skull base chordomas. It is even a matter of hardware, knowing how good you can trust your machine and where the caveats lie. Bear in mind, that many of the results we have now are based on experience with "prototype" machines, like the ones installed in Boston and the PSI. The complexity of technology is astonishing and there are still several unrecognized issues, especially when it comes to active scanning. Have a look over at Europe and you'll see that the companies have several issues getting their gantries online. RPTC in Munich, Germany had something like 5 years of delay, due to beam stability issues. WDPTZ in Essen, Germany has still not started treatment and is also delayed by something like 3 years. Kiel, Germany and Marburg, Germany (both Siemens-projects) had their installations built and the equipment installed, only to have them shut down and disassembled months before scheduled commission (although these were actually heavy ions projects, which is a whole different ballgame). Even the HIT in Heidelberg, Germany has had issues for several years and was delayed for quite some years.

Anyways, I was not referring to MD Anderson, I was referring to UTSW project (which is why, I said that your friend would get sick in 8 years).

 

[jaharmy]

.

 

[medgator]

Your issue is clearly with the utility of protons and the facilities "allowed" to house them. Again, NOT the point I'm making. Try as you might, you and I are not fighting the same battle. More research should be done regarding protons and this can only be done at proton centers, thus I do see a need at UTSW. One day it may be a great proton center. Maybe it won't. As far as who should be allowed to build a facility, take your struggle to ASTRO and the private ventures that funds these facilities - I am not the one.

So the 17 that already online (or coming online) in this country alone aren't enough to do that research?

 

[jaharmy]

.

 

[jaharmy]

So the 17 that already online (or coming online) in this country alone aren't enough to do that research?

.

 

[deleted4401]

MDACC was basically forced to get protons. The Houston area Urorad groups devastated most practices prostate cancer numbers, and for them to make up a vast amount of revenue, they needed to find a cash cow. And, voila, they have protons. Has very little do with research and development of a novel treatment modality. In fact, the majority of pediatric cases (when I was applying for presidency) were treated by Dr. Paulino at Baylor/Texas Children's, not MDACC. It's not like they partnered with one of the leading pediatric radiation oncologists in the country working 1 mile away, nor is it a true collaboration with Texas Children's.

It's fine and probably similar to what's happening in Dallas, as there are Urorad groups there. It's not UTSW's fault. It's CMS/Medicare and the Stark Law loophole. If the economics/reimbursement/regulations weren't so screwed up, they wouldn't have the need. I don't blame the institutions at all. They are acting legally and ethically, but most importantly, in their chief economic interest. We're pretty sure protons aren't that much worse for prostates and the dosimetry is probably better. It's just an economics decision. If it paid the same as IMRT, there would still be 5 centers in the country. It's that simple.

 

[StudentRadOnc]

One person does not make "expertise", especially not in the world of protons.
It takes a whole team to run a place like that, I've experienced that myself, having worked in a proton facility for some time.

You need the physics, you need the doctors, you need the cooperating surgeons, you need lots of stuff to perform such a complex treatment as skull base chordomas. It is even a matter of hardware, knowing how good you can trust your machine and where the caveats lie. Bear in mind, that many of the results we have now are based on experience with "prototype" machines, like the ones installed in Boston and the PSI. The complexity of technology is astonishing and there are still several unrecognized issues, especially when it comes to active scanning. Have a look over at Europe and you'll see that the companies have several issues getting their gantries online. RPTC in Munich, Germany had something like 5 years of delay, due to beam stability issues. WDPTZ in Essen, Germany has still not started treatment and is also delayed by something like 3 years. Kiel, Germany and Marburg, Germany (both Siemens-projects) had their installations built and the equipment installed, only to have them shut down and disassembled months before scheduled commission (although these were actually heavy ions projects, which is a whole different ballgame). Even the HIT in Heidelberg, Germany has had issues for several years and was delayed for quite some years.

Anyways, I was not referring to MD Anderson, I was referring to UTSW project (which is why, I said that your friend would get sick in 8 years).

I don't think you can make these points and NOT reference a site like MD Anderson. Their proton facility has been functional since 2006 (which is of course not long at all) and I do consider their work with protons great. In regards to UTSW, of course you need more than 1 expert to qualify a center with 'expertise' thus that's why this is called an 'example.' Texas has tons of money and if they felt the desire could recruit, recruit, recruit.

 

[StudentRadOnc]

So the 17 that already online (or coming online) in this country alone aren't enough to do that research?

Some of these sites do not have high caliber research so for some sites, no, I don't think it is enough.

 

[StudentRadOnc]

It's reasonable that you would stand up for UTSW getting a proton center, since your father is on faculty. However, when pressed with why Texas needs another proton center your rationale have been:

1) The other locations are too far and logistically difficult for parents- In reality, for the cost associated the 2-4 hour distance (houston, shreveprot, OKC) is really not bad and programs are in place to help those with financial needs.

2) Great programs should have protons- This only makes sense if protons provide a wide scale benefit and are a backbone of the radiaton oncologist treatment paradigms. That is not the case currently with protons having evidence based rationales in limited subsites.

3) Now you say ". I think these programs should be chosen based on geographical/population density and quality of institution so that the appropriate research can go along with/test treatment utility. I see a need in Dallas."- Dallas has a population of roughly 1.2 million (per Wikipedia). Per the NCI, 10,000 kids were diagnosed with cancer so roughly speaking (per NCI) so a rough estimate is that there are 50 new pediatric cancers diagnosed per year in Dallas with other cases adding another 50. For 100 justified cases per year, you think a $100 million dollar plus facility is reasonable? Wouldn't it make more sense to send residents for a rotation to a pre-existing facility to get their education?

I see a need for the sake of more research. If an exceptional center is located in an area so that families don't have to leave their jobs, move to a new city, drive 4 hours, and find a new place to live, that's great. If not, ok. I'm not suggesting these facilities should spawn like starbucks.

 

[Palex80]

I see a need for the sake of more research. If an exceptional center is located in an area so that families don't have to leave their jobs, move to a new city, drive 4 hours, and find a new place to live, that's great. If not, ok. I'm not suggesting these facilities should spawn like starbucks.

I think you are exaggerating a bit, when it comes to the problems families have to face, when their children are in need of proton treatment.
Like I said before, I have worked in a European proton center, one that treats patients from dozens of countries in Europe on a regular basis.

What you basically need is logistics to take care of this issues. When a proton therapy in the US is charged for over $100.000 (I've even heard of "treatment-packages" for complex tumors with anaesthesia for the children going over $250.000), making it possible for the child and his parent(s) to be relocated for 6 weeks shouldn't be the biggest problem, at least financially speaking. That's probably a rational, average guess for treating a rhabdomyosarcoma, astrocytoma, ependymoma or medulloblastoma for a kid, sorry I am not familiar with all US protocols.

In the proton facility I worked, there were several guesthouses around the complex, giving the families a place to live. Sometimes only one of the two parents came along, other times the entire family practically moved in. The insurance companies paid some of these costs, the rest was covered through charity funds.
If you calculate something like $100 per person per day (which is actually quite generous) for eating & sleeping, this means $700 per week. A family of four (2 parents, one healthy kid, one sick kid) would thus need $16,800 for 6 weeks of treatment (incl. the weekends).

Is that too much to pay, when the treatment alone costs at least 6 to 15 times that amount?
There are definitely enough charities, interested to pay some of these costs or construct guest houses, etc. I mean, we are talking here about the USA, the country with the most active charity programs worldwide!

 

[deleted4401]

We are charitable SOBs, aren't we? Well, it's sort of like the 90s when the Mayo Clinic had more MRIs than Canada. We let the economic incentives dictate medical resource capitalization. There are pluses and minuses. This one is going to bankrupt a lot of cancer centers once proton reimbursement falls or NCCN recommendations are made and insurances stop covering it.

 

[seper]

I'm perplexed why Medicare still reimburses $100K for prostate proton XRT (somebody said reimbursement increased??) when accumulating evidence suggests that low risk prostate patients should not be diagnosed and treated.

 

[StudentRadOnc]

What makes UTSW a better place for research than MGH or MDACC? These are two of the premier institutions in our country. The reality is no one is really willing to for the photons (IMRT) v. protons trial at their institution because equivalence would essentially devalue their technology. Thats the research that needs to be and should be done but won't be done. Is UTSW or any other new center going to be different, Im skeptical. So what research would UTSW be doing that the 17+ protons centers ahead of them can't?

You'd have to ask UTSW for that one.

 

[StudentRadOnc]

I'm perplexed why Medicare still reimburses $100K for prostate proton XRT (somebody said reimbursement increased??) when accumulating evidence suggests that low risk prostate patients should not be diagnosed and treated.

Nicely put. I place no fault with the individual institution trying to remain competitive or further their science as long as research is a premium.

 

[radiaterMike]

We are charitable SOBs, aren't we? Well, it's sort of like the 90s when the Mayo Clinic had more MRIs than Canada. We let the economic incentives dictate medical resource capitalization. There are pluses and minuses. This one is going to bankrupt a lot of cancer centers once proton reimbursement falls or NCCN recommendations are made and insurances stop covering it.

NCCN already states that proton therapy for prostate cancer should not be universally utilized.

 

[jaharmy]

What makes UTSW a better place for research than MGH or MDACC? These are two of the premier institutions in our country. The reality is no one is really willing to for the photons (IMRT) v. protons trial at their institution because equivalence would essentially devalue their technology. Thats the research that needs to be and should be done but won't be done. Is UTSW or any other new center going to be different, Im skeptical. So what research would UTSW be doing that the 17+ protons centers ahead of them can't?

Wow! Where do I begin on this one? First, a quick fact check. Although, it might be helpful to your argument to pick the smaller number - the Dallas-Ft. Worth Metroplex actually has a population of 6.5 million (4th largest in US) according to wikipedia. Second, since when do any two institutions have a monopoly on research? Any person with a cursory knowledge of the research world could tell you that UTSW produces significantly more impactful basic science research than MD Anderson, and generally the more people working on a topic the sooner a definitive answer will be reached.

I'm really trying to understand your clear contempt for UTSW, but I am having a hard time, especially when you skew the facts and make blanket generalizations without providing any real substance for your argument. "So what research would UTSW be doing that the 17+ protons centers ahead of them can't?" I would bet on 5 Nobel prize winners (more than any other medical school), 19 National academy members and 12 Howard Hughes Investigators, but that's just me. Facts!!