Protons are blowing Rad Onc's boat out the CMS water

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The only [that I'm aware of {knocks on wood}] issue I ever had with IBD was a UC patient. I treated prostate only and he had a local flare at the splenic flexure well out of field shortly after completing.

Not sure if distal radiation inflammation can prompt a more proximal flare, but luckily was controlled with typical measures.
 
To amplify my story, my entire colon flared. One nite I was very weak, went into the shower, and proceeded to pass a clot that was for all intents and purposes a BLOOD CLOT CAST of damn near my whole colon.Went to the hospital with a Hgb of 5.8, got blood and steroids and then I got myself tuned up for a colectomy because that was NEVER going to happen to me again.

Correct “crit” to Hgb. A little difference.
 
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drewdog1973 said:
Something sounds odd about that dose.

maybe confused and it was 7000/35
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that sounds very familiar. However, I am very pleased to know that many of y’all think the 5500 with ADT for early biochemical relapse was ok, cause that is all i got.
 

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David Chang's great response on the limited data but high implementation of protons...followed by Drew Moghanaki's idiotic response. Ridiculous.
 
SubserviantToABR said:

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David Chang's great response on the limited data but high implementation of protons...followed by Drew Moghanaki's idiotic response. Ridiculous.
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I don’t think I’d consider it a “non-overlapping” issue. It’s all interwoven.

In fact, when you read the original long form document by CMS for rationale behind APM, they specifically singled out a “case example” for proton therapy for prostate cancer as an example of low value care. That got some eyes on us (the field) .
 
BobbyHeenan said:
I don’t think I’d consider it a “non-overlapping” issue. It’s all interwoven.

In fact, when you read the original long form document by CMS for rationale behind APM, they specifically singled out a “case example” for proton therapy for prostate cancer as an example of low value care. That got some eyes on us (the field) .
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Proton guy gets schooled on NCCN guidelines
 
medgator said:


Proton guy gets schooled on NCCN guidelines
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I usually found that Steven Frank is very much a blowhard. He coined the term, MARS - MRI assisted radiosurgery, for his use of MRI for prostate brachy (MRI-assisted radiosurgery and brachytherapy for prostate cancer treatment). Just a quick search on CT.gov showed that there is no trials collecting data on the utility of MRI for brachy from Steven Frank. Again, another additional costs for patients without any proven benefits.
 
He’s citing the NAPT and Texas guidelines he probably wrote himself.

Im actually bullish on protons for head and neck. But we’ll know soon enough after the trial is done.

Aside - I’m willing to bet my H/N patients that walk in emaciated and can’t hardly swallow pre treatment will still need feeding tubes if I offer them protons. They ain’t getting off a delta flight to visit MDACC , they’re riding a city bus to my clinic or getting someone from church to drive them. Then we can get them donated Boost (uninsured) to put in their G tubes .
 
Ray D. Ayshun said:
View attachment 341004
I've only used photons. Don't recall ever ordering a gastronomy tube. Sounds more like an Alinea thing.
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BobbyHeenan said:
He’s citing the NAPT and Texas guidelines he probably wrote himself.

Im actually bullish on protons for head and neck. But we’ll know soon enough after the trial is done.

Aside - I’m willing to bet my H/N patients that walk in emanciated and can’t hardly swallow pre treatment will still need feeding tubes if I offer them protons. They ain’t getting off a delta flight to visit MDACC , they’re riding a city bus to my clinic or getting someone from church to drive them. Then we can get them donated Boost (uninsured) to put in their G tubes .
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Would think that proton dosimetry is very sensitive to changes is body contour/postioning/tumor shrinkage. I think future of radiation in p16 + head and neck is 30 gy in most patients (hypoxi tracer)
 
BobbyHeenan said:
He’s citing the NAPT and Texas guidelines he probably wrote himself.

Im actually bullish on protons for head and neck. But we’ll know soon enough after the trial is done.

Aside - I’m willing to bet my H/N patients that walk in emaciated and can’t hardly swallow pre treatment will still need feeding tubes if I offer them protons. They ain’t getting off a delta flight to visit MDACC , they’re riding a city bus to my clinic or getting someone from church to drive them. Then we can get them donated Boost (uninsured) to put in their G tubes .
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Even if they could make the trip to the Anderson, pretty sure their Medicaid wouldn't get them through the front door and they'd end getting treated at Baylor
 
medgator said:
Medicaid wouldn't get them through the front door
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What is the root cause of this? Is it institutions refusing the Medicaid or Medicaid not paying for out of state services?

This is a huge issue where I am as there are several world class institutions out of state and non in state. The need to refer to these places is frankly very rare but when it occurs it is uniformly a young person with advanced disease and these folks are disproportionately Medicaid patients.

I would advocate for some sort of rule like: 1. All PPS exempt or even NCI designated cancer centers must accept all forms of Medicaid or 2. Medicaid must pay for exceptional care out of state when not available in state. I'm guessing number one would fall under federal jurisdiction (maybe a commerce clause intervention?) and number two would have to be a state by state mandate?
 
communitydoc13 said:
What is the root cause of this? Is it institutions refusing the Medicaid or Medicaid not paying for out of state services?

This is a huge issue where I am as there are several world class institutions out of state and non in state. The need to refer to these places is frankly very rare but when it occurs it is uniformly a young person with advanced disease and these folks are disproportionately Medicaid patients.

I would advocate for some sort of rule like: 1. All PPS exempt or even NCI designated cancer centers must accept all forms of Medicaid or 2. Medicaid must pay for exceptional care out of state when not available in state. I'm guessing number one would fall under federal jurisdiction (maybe a commerce clause intervention?) and number two would have to be a state by state mandate?
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Probably parties on both sides that aren't ready to play ball. PPS exempt would probably prefer taking cash patients from overseas rather than accept sub Medicare rates from Medicaid patients.

Medicaid administrators usually like to contract with the lowest cost providers (no further explanation needed there).
 
mikesheree said:
I was supposed to receive a total of 7000 ( I THINK it was 250 x 28 days) for a 1.3 cm 4+4 in one lobe confined to prostate 2 years after radical prostatectomy. There was a question of seminal vesicle involvement, BUT what the paths are describing is involvement of the INTRAPROSTATIC portion of the seminal vesicles which does not count ( i was a path for decades, (U.S grad 1977). Tumor arose at area of root of seminal vesicle. They had to stop tx because i had a hx of severe pan ulcerative colitis. Got total abd colectomy due to hemorrhage with permanent ileostomy. Too risky to remove sigmoid due to prior surgery x 2 and the radiation. So, it really was a T2a, N0, M0 4+4=8. No one would listen to me but it had to be treated one way or another and there is no question there was a recurrence. 0.2ng x 2 at same lab. My pre op PSA was only 4.0 with small palpable) nodule.
The section taken of the seminal vesicle is normal. But there is tumor with the typical seminal vesicles pigment within the prostate. Nada in muscular wall of extraprostatic seminal vesicle. They thought the UC would be ok with IMRT.
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I was initially going to post something snarky, but the history of severe UC makes the rest of the post makes sense. Sorry you had this experience, but h/o severe UC is a risk factor for badness during pelvic radiation. Doing 70Gy in 28 fraction after you've had a radical prostatectomy.... that's not ideal. I guess they figured you had gross disease and watned to get you done ASAP. Anecdotes and n=1, but these are stories that make me gun shy.
 
communitydoc13 said:
What is the root cause of this? Is it institutions refusing the Medicaid or Medicaid not paying for out of state services?

This is a huge issue where I am as there are several world class institutions out of state and non in state. The need to refer to these places is frankly very rare but when it occurs it is uniformly a young person with advanced disease and these folks are disproportionately Medicaid patients.

I would advocate for some sort of rule like: 1. All PPS exempt or even NCI designated cancer centers must accept all forms of Medicaid or 2. Medicaid must pay for exceptional care out of state when not available in state. I'm guessing number one would fall under federal jurisdiction (maybe a commerce clause intervention?) and number two would have to be a state by state mandate?
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In case of mdacc they are a state (of Texas) funded institution unlike most of the other pps exempt centers. Quite egregious
 
SubserviantToABR said:
Lest not forget, they will continue to use this hammer for the nail:
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Technology can’t go backwards? Maybe not, but unfortunately critical thinking and reason can. I think a more honest statement would be “expensive technology with no return policy that we bought without a proven clinical justification despite 30 years of trying can’t just sit there collecting dust.” I also bet if payers decided they would only reimburse 3D rates, people would go backwards to be able to bill for IMRT and SBRT.
 
People always talk crap about imrt but there actually are some randomized trials right? Nutting trial in head neck, breast trial. At least people tried. Proton people haven’t done anything.

real question is if mrgrt will be like protons or if someone will do an actual trial. And though I love some of the authors the momentum thing in the red journal is not a trial
 
MegaVoltagePhoton said:
People always talk crap about imrt but there actually are some randomized trials right? Nutting trial in head neck, breast trial. At least people tried. Proton people haven’t done anything.

real question is if mrgrt will be like protons or if someone will do an actual trial. And though I love some of the authors the momentum thing in the red journal is not a trial
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There are some big names in the MR consortiums (like Chris Crane) so there is hope but it will be a looong time. Pretty much everything at this point is feasibility. Nothing comparing MR to standard IGRT that I am aware of.

Honestly, protons have set a horrific precedent. If you firmly believe in the technology or have stake in it, why in the world would you risk a negative trial (and pay for it just to add insult to injury)? Payers and consensus guidelines have already shown that if you prove that you can do something with a new technology, there is no need to prove it actually fills an unmet need or does any better than existing devices.
 
Just curious who pays for proton for let's say prostate ca?
- Patients (rich pts)?
- Insurance company?
 
ramsesthenice said:
There are some big names in the MR consortiums (like Chris Crane) so there is hope but it will be a looong time. Pretty much everything at this point is feasibility. Nothing comparing MR to standard IGRT that I am aware of.

Honestly, protons have set a horrific precedent. If you firmly believe in the technology or have stake in it, why in the world would you risk a negative trial (and pay for it just to add insult to injury)? Payers and consensus guidelines have already shown that if you prove that you can do something with a new technology, there is no need to prove it actually fills an unmet need or does any better than existing devices.
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Chris Crane? Yikes, not too impressed honestly especially after the mednet debacle.

I looked on the ViewRay website, they list a randomized trial for prostate sbrt. I guess that’s something if it is real. There do appear to be some smaller phase 2 also.
 
Neuronix said:
Protons for prostate is allowed by CMS. So, medicare pays 80%, rich old men pay 20%.
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Here is what I am not sure of: Medicare pays 80% of cms rate and insurance pays 20% of rest of cms rate, but doesn’t the insurance then also kick in and pay the difference between the Medicare/cms rate and the negotiated rate. (In that case, they pay a lot more than 20% cms)

ie if Medicare rate for mri is 100$ but Mayo Clinic has negotiated rate w/blue cross of 300. Does Medicare pay 80$ and then insurance 220$ ?
 
Seems to be a common theme in this field for people to have thin skin like a sushi. It is a field of stinky sushi blobs who talk.

Crane can’t take it when someone orders pet. LK wants to gaslight people but cannot take the kitchen heat and said she was “bullied” and has a private twitter. SAD. Must be a GI thing.

i know i know, the lady doth protest too much.
 
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RickyScott said:
Here is what I am not sure of: Medicare pays 80% of cms rate and insurance pays 20% of rest of cms rate, but doesn’t the insurance then also kick in and pay the difference between the Medicare/cms rate and the negotiated rate. (In that case, they pay a lot more than 20% cms)

ie if Medicare rate for mri is 100$ but Mayo Clinic has negotiated rate w/blue cross of 300. Does Medicare pay 80$ and then insurance 220$ ?
Click to expand...

Most private insurers are not routinely covering protons outside of special cases. My experience with Medicare Advantage or Medigap plans is that they are big time cheapskates.

So in these cases people pay out of pocket their 20% straight medicare without or instead of using supplemental or gap insurance.
 
I got to speak with a higher up at FDA oncology a few years back (totally rando, I'm not connected) who told me that pharma will put in the extreme investment for drug development in relatively small populations (see most cancers) because they are allowed to charge whatever they want in this country for an approved drug. In principle, (exempting the latest Alzheimer's SNAFU) the drug has to demonstrate improved efficacy (be that a 4 month PFS benefit or something more significant) over the SOC.

Compare that to the adoption of protons with higher charges in radonc,

30+ years of experience with protons, no meaningful high level evidence of improved clinical outcomes and dissemination of the tech throughout large centers with a goal to charge more (whatever they can, see first post in thread).

The proper way for protons to have been disseminated would have been as follows:

4 major cancer centers develop protons with a goal to improve the technology, treat niche patients (see base of skull lesions and peds) and study clinical outcomes. They partner with industry for investment and development and to float operational costs. (At some point this is roughly where we were exempting the niche pt part. I can't speak to level of industry cooperation). The money here comes from industry and industry has to believe that the risk/investment is worth it (they have to be true believers of the product/initiative).

Multiple clinical trials are run at these institutions (with industry help) evaluating for improved efficacy over SOC. If first trials are clearly negative, repeat trials could be attempted when paradigm changing improvements in tech are made (IMPT).

If improved efficacy over SOC clearly demonstrated, tech marketed to additional centers and community with new payment schedule reflecting cost of care/difficulty of administration.

I'm guessing if the above model were actually followed, industry would have bailed and there would now only be a few charity proton centers nationally for kids. Can you imagine a proton vs photon trial showing a 4 month PFS benefit? (if it does it's chance). Payors and regulatory bodies already telling us to accept higher acute toxicity for cost purposes.

What happened in late 2000s, early 2010s when protons just exploded? I'm guessing because of the regulatory difference between devices and drugs, industry just bypassed the investment (and uncertainty) in finding proof of better outcomes and just figured out how to make protons more scalable. Social pressure took over and here we are.

We really need to start giving drugs.
 
let’s be honest, everyone’s concern with protons is not the lack of data. There is no RCT to show that VMAT offered anything over sliding window IMRT. We all just looked at the smooth plan and liked it better the one with high dose spikes (and liked the shorter beam-on time). We didn’t need an RCT because VMAT was readily available for anyone and the plans look great. Proton plans look even better (whether you get what you think you are getting is another convo entirely).

The principle objection to protons is that they cost more and aren’t (currently) available to everyone. If protons billed like IMRT, no one would care… but as it stands, it plays into the big guy vs. little guy dynamic… and seems to really rub some people the wrong way
 
Lamount said:
let’s be honest, everyone’s concern with protons is not the lack of data. There is no RCT to show that VMAT offered anything over sliding window IMRT. We all just looked at the smooth plan and liked it better the one with high dose spikes (and liked the shorter beam-on time). We didn’t need an RCT because VMAT was readily available for anyone and the plans look great. Proton plans look even better (whether you get what you think you are getting is another convo entirely).

The principle objection to protons is that they cost more and aren’t (currently) available to everyone. If protons billed like IMRT, no one would care… but as it stands, it plays into the big guy vs. little guy dynamic… and seems to really rub some people the wrong way
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It is really about the business model. Protons are often used to lure patients to centers charging 5x cms rates across the board. Monopolistic (either by name or geography) hospitals can charge imrt “rates” for protons and do very well if the imrt rates are this high. Both UPenn and Mayo have boasted about charging imrt rates for protons, neglecting to mention that the imrt rates are sky high. In Jordan’s data set, protons were something like 3% of utilization but 50+% of charges. That is insane, not just little vs big resentment. We are talking breaking the system/something rotten in state of Denmark/ unsustainable perfidy.
 
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RickyScott said:
It is really about the business model. Protons are often used to lure patients to centers charging 5x cms rates across the board. Monopolistic (either by name or geographic) Centers can charge imrt “rates” for protons and do very well if the imrt rates are this high. Both UPenn and Mayo have boasted about charging imrt rates for protons, neglecting to mention that the imrt rates are sky high. In Jordan’s data set, protons were something like 3% of utilization but 50+% of charges. That is insane, not just little vs big resentment. We are talking breaking the system/something rotten in state of Denmark/ type of unsustainable perfidy.
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I propose that our entire specialty is based on enticing people with technology. This is not unique to protons

Your second argument is stronger. There shouldn’t be such a price differential… but I would point out that the “system” has much greater enemies than protons. I forget the exact number, but doesn’t rad onc in toto comprise a vanishingly small percentage of total oncology spending?
 
Lamount said:
Your second argument is stronger. There shouldn’t be such a price differential… but I would point out that the “system” has much greater enemies than protons. I forget the exact number, but doesn’t rad onc in toto comprise a vanishingly small percentage of total oncology spending?
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It does, but macroscopically I would argue that very roughly, the total dollars spent on radiation can be looked at as a constant. (May increase few percent per year). So if protons take 50+% (and probably growing) of the pie …guess what the means for everyone else. Bit of a zero sum game unless you can make the case that total radonc spending is increasing substantially.
 
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Lamount said:
let’s be honest, everyone’s concern with protons is not the lack of data. There is no RCT to show that VMAT offered anything over sliding window IMRT. We all just looked at the smooth plan and liked it better the one with high dose spikes (and liked the shorter beam-on time). We didn’t need an RCT because VMAT was readily available for anyone and the plans look great. Proton plans look even better (whether you get what you think you are getting is another convo entirely).

The principle objection to protons is that they cost more and aren’t (currently) available to everyone. If protons billed like IMRT, no one would care… but as it stands, it plays into the big guy vs. little guy dynamic… and seems to really rub some people the wrong way
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True, but obvious, no? Of course there's a higher bar to adopt increasingly more expensive and complex treatments. Should that not be the case?
 
Lamount said:
let’s be honest, everyone’s concern with protons is not the lack of data. There is no RCT to show that VMAT offered anything over sliding window IMRT. We all just looked at the smooth plan and liked it better the one with high dose spikes (and liked the shorter beam-on time). We didn’t need an RCT because VMAT was readily available for anyone and the plans look great. Proton plans look even better (whether you get what you think you are getting is another convo entirely).

The principle objection to protons is that they cost more and aren’t (currently) available to everyone. If protons billed like IMRT, no one would care… but as it stands, it plays into the big guy vs. little guy dynamic… and seems to really rub some people the wrong way
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vmat never necrosed kids brainstems
pubmed.ncbi.nlm.nih.gov

Protons, the brainstem, and toxicity: ingredients for an emerging dialectic - PubMed

Protons, the brainstem, and toxicity: ingredients for an emerging dialectic
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
Lamount said:
If protons billed like IMRT, no one would care
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I agree. But would they be as pervasive as they are now if they billed this way? Would the existing data and work flow requirements and necessary investment and clinical experience in centers that have had protons for a while been enough to drive their growth if there was no billing disparity?

Put another way, when APM reimburses per case will protons be more utilized because they are that good or less utilized because they are a pain in the neck to do well and they are just not worth it? I will be IMRTing more pts (but not all) under an APM because it's usually clearly better for pts (Even 30 Gy AP/PA causes esophagitis and diarrhea), work flow is routine and I am confident in QA/dosimetry.

Lamount said:
This is why we need robust/LET based optimization
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What does this really mean? I'm being serious here. To me it means that the chemistry of energy transfer changes dramatically as protons lose energy and that RBE is not uniform across a plan (as opposed to photons, where our dosimetry on the molecular level is fairly independent of things like depth of tissue). This seems like an extremely tough problem to solve as things like proton capture probabilities could be significantly dependent on stuff like pH?
 
communitydoc13 said:
I agree. But would they be as pervasive as they are now if they billed this way? Would the existing data and work flow requirements and necessary investment and clinical experience in centers that have had protons for a while been enough to drive their growth if there was no billing disparity?

Put another way, when APM reimburses per case will protons be more utilized because they are that good or less utilized because they are a pain in the neck to do well and they are just not worth it? I will be IMRTing more pts (but not all) under an APM because it's usually clearly better for pts (Even 30 Gy AP/PA causes esophagitis and diarrhea), work flow is routine and I am confident in QA/dosimetry.


What does this really mean? I'm being serious here. To me it means that the chemistry of energy transfer changes dramatically as protons lose energy and that RBE is not uniform across a plan (as opposed to photons, where our dosimetry on the molecular level is fairly independent of things like depth of tissue). This seems like an extremely tough problem to solve as things like proton capture probabilities could be significantly dependent on stuff like pH?
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The relationship between the LET and RBE can be modeled pretty well with Monte Carlo simulation… but it’s pretty obvious now that you shouldn’t treat the distal end of your target to full dose when it resides within a dose-limiting serial OAR. Monte Carlo simulation is an old technology but it only recently became scalable to clinical proton optimization. This in combination with robust/LET based optimization, and dual energy CT have decreased uncertainties significantly.

I think it is far more likely that our understanding of proton dosimetry will improve significantly with our computational abilities. It’s far less likely that it is simply unknowable
 
We already have the results of the thought experiment of what would happen if a charged particle technology existed that everybody has access to, isn't cost prohibitive, and if appropriately used, has advantages over photons in specific situations. They are called ELECTRONS. You never see people try to build advertising campaigns around electrons and shockingly end up being used when the clinical scenario calls for them and not shoved into every single disease site
 
Lamount said:
I think it is far more likely that our understanding of proton dosimetry will improve significantly with our computational abilities. It’s far less likely that it is simply unknowable
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Range uncertainties in proton therapy and the role of Monte Carlo simulations - PMC

The main advantages of proton therapy are the reduced total energy deposited in the patient as compared to photon techniques and the finite range of the proton beam. The latter adds an additional degree of freedom to treatment planning. The range in ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Holy cow. Even simple grids representing density inhomogeneity create major range uncertainties. The physics in undoubtedly cool but seems almost like trying to come up with a computer fix for an airplane where you've ruined the center of mass (737max).

Well, make it work and make it robust. Sounds like a noble career goal.
 
RickyScott said:
Here is what I am not sure of: Medicare pays 80% of cms rate and insurance pays 20% of rest of cms rate, but doesn’t the insurance then also kick in and pay the difference between the Medicare/cms rate and the negotiated rate. (In that case, they pay a lot more than 20% cms)

ie if Medicare rate for mri is 100$ but Mayo Clinic has negotiated rate w/blue cross of 300. Does Medicare pay 80$ and then insurance 220$ ?
Click to expand...

Where we have contracts >100% of Medicare, the private insurer kicks in the remainder up to our negotiated rates, so we end up getting >20%. We do not negotiate a separate rate for straight PPO vs. secondary plans. I suspect hospitals are similar and end up getting enormous payments from the health plans through the secondary insurance. That's the real racket here. It's also why commenting on slight Medicare utilization differences between hospitals and freestanding centers is a red herring...because the hospitals are killing it on the back end with these secondary insurances.

Neuronix said:
Most private insurers are not routinely covering protons outside of special cases. My experience with Medicare Advantage or Medigap plans is that they are big time cheapskates.

So in these cases people pay out of pocket their 20% straight medicare without or instead of using supplemental or gap insurance.
Click to expand...

When patients have straight Medicare, the secondary can't deny payment if Medicare pays...they have to follow CMS's lead. Medicare Advantage is different because the patient has essentially assigned his Medicare over to the health plan and that does free up the health plan to some extent. The health plan still technically has to follow Medicare guidelines, but they can restrict their networks so that this service is not offered "in network."
 
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