Ulcerative colitis and proton beam tx

[deleted314957]

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How does a hx of UC affect your decision making as regards proton beam tx for T2 and T3 prostate ca?

 

[Gfunk6]

It doesnt

 

[seper]

I'd still proceed with insertion of balloon as planned.

 

[napoleondynamite]

I'd still proceed with insertion of balloon as planned.

Quite possibly the best post ever on SDN, hahaha!

 

[Gfunk6]

an off-shoot question...why offer protons off-protocol for a T2/T3 prostate cancer with outcomes with IMRT being what they are? Is there any prospective data that really shows that protons are an appropriate option particularly when factoring in cost?

$$$

 

[BobbyHeenan]

$$$

I go through this every. single. week. in my my practice.

It's very difficult to convince the lay person that IMRT is just as good for their prostate cancer when they're bombarded with commercials, free PSA screening events at grocery stores (seriously), a shiny new proton clinic, and the idea that proton therapy "goes to the target and stops." How could it not be better with all of those things?

I print out NCCN guidelines and ASTRO choosing wisely papers and go over them with patients. I basically tell them that if I had prostate cancer and the choice between proton and photon, I'd choose the one that was closest to my house and covered by insurance. Maybe the randomized trial will show results I'm not seeing yet, but it just doesn't seem like there's much of a difference in outcomes or toxicity.

The sad thing is I have had patients dip into their retirement to pay large sums of cash for protons for their prostate when their insurance denied it and suggested IMRT instead.

 

[RadOncDoc21]

I go through this every. single. week. in my my practice.

It's very difficult to convince the lay person that IMRT is just as good for their prostate cancer when they're bombarded with commercials, free PSA screening events at grocery stores (seriously), a shiny new proton clinic, and the idea that proton therapy "goes to the target and stops." How could it not be better with all of those things?

I print out NCCN guidelines and ASTRO choosing wisely papers and go over them with patients. I basically tell them that if I had prostate cancer and the choice between proton and photon, I'd choose the one that was closest to my house and covered by insurance. Maybe the randomized trial will show results I'm not seeing yet, but it just doesn't seem like there's much of a difference in outcomes or toxicity.

The sad thing is I have had patients dip into their retirement to pay large sums of cash for protons for their prostate when their insurance denied it and suggested IMRT instead.

Its all about marketing, I was going to re-name my linac "Cure-All." You think that would help me bring in more patients?

 

[medgator]

I go through this every. single. week. in my my practice.

It's very difficult to convince the lay person that IMRT is just as good for their prostate cancer when they're bombarded with commercials, free PSA screening events at grocery stores (seriously), a shiny new proton clinic, and the idea that proton therapy "goes to the target and stops." How could it not be better with all of those things?

I print out NCCN guidelines and ASTRO choosing wisely papers and go over them with patients. I basically tell them that if I had prostate cancer and the choice between proton and photon, I'd choose the one that was closest to my house and covered by insurance. Maybe the randomized trial will show results I'm not seeing yet, but it just doesn't seem like there's much of a difference in outcomes or toxicity.

The sad thing is I have had patients dip into their retirement to pay large sums of cash for protons for their prostate when their insurance denied it and suggested IMRT instead.

Show them the jama study suggesting no benefit and a possible detriment in terms of gi toxicity. Or mention how many private insurers have stopped covering it in low-risk disease (at least in California). Our nearest proton center is several hours away but the fact remains that Medicare still covers it, and many people have that, so unless they are paying that 20% out of pocket and/or have to travel really far, it probably doesn't take much to sway them

 

[OTN]

I would add the spacer material (can't remember the trade name for it now) between the prostate and the rectum to allow for better rectal sparing. I would then treat with IMRT and IGRT, because proton beam therapy for prostate cancer is RIDICULOUS.

 

[BobbyHeenan]

Show them the jama study suggesting no benefit and a possible detriment in terms of gi toxicity. Or mention how many private insurers have stopped covering it in low-risk disease (at least in California). Our nearest proton center is several hours away but the fact remains that Medicare still covers it, and many people have that, so unless they are paying that 20% out of pocket and/or have to travel really far, it probably doesn't take much to sway them

I have done that as well.

Even though I post on internet message boards, I am far from a basement dweller and have good rapport with patients. My facility is not a dump but it's certainly not a bright shiny new proton center. However, I am definitely batting less than .500 on proton vs. IMRT prostate consults. I know these patients are not being harmed with protons, but it does upset me when patients dip into their own cash/retirement to pay for it when their insurance won't cover it. That's upsetting to me, because I try to save for my own retirement and it hurts me to think someone paid tens of thousands out of pocket for treatment of their low risk prostate cancer.

I try to keep some anonymity on here, so I won't expand much further, but let me say that as mentioned above - marketing and scare tactics about photons/2nd malignancy/etc trump a journal article any day. They bring out a picture of a photon vs. a proton dose distribution in a shiny ad and it's a game changer. It's very hard for logic to trump a pictorial showing less radiation to "all that tissue" even if it has no clinical consequence.

.... because proton beam therapy for prostate cancer is RIDICULOUS.

....But not as ridiculous as anal (two different patients) and right sided breast treatment. Both of which I've personally seen treated. If insurance will pay for it, you better believe they're getting protons.

 

[OTN]

Right-sided breast?? Wow. I can't believe the insurance companies aren't pushing back harder than they already are.

 

[medgator]

This is what I struggle with. While I don't think they are being harmed from the treatment, are they being harmed by having to pay more for treatment where we dont know that there is any additional benefit to standard therapy? In line with what you mention, I think of my parents who have saved for retirement and could easily be convinced to give some of that for protons if they needed RT. One would hope that as physicians, regardless of whether we work at a proton center or not, that we would think about the costs that patients have to deal with it and the societal implications of offering protons in situations with limited comparative data and then decide if protons really makes sense. The other issue is one of down the road, if proton therapy keeps being used without clinical data beyond pretty pictures, what happens when insurance companies clamp down such that those that really need it struggle to get it.

The bigger question is whether the specialty is being harmed by overuse of a more expensive treatment modality where good standard options exist.

It only gets us under the microscopic more in a bad way. Just look at what med onc deals with now with so many targeted and immune therapies with six-figure annual costs. Payors are going to cry uncle sooner or later. They already have to some degree. Any special treatment or chemo agent usually needs prior auth and/or peer-to-peer review quite often with Medicare replacement and many private insurers

 

[Gfunk6]

We all like to piss on protons in this forum, but consider the simple economics of the situation. We have a procedure (protons) which is reimbursed much more handsomely than another procedure (IMRT).

Can you really blame people for doing it? We are guilty of the same thing to a lesser degree (e.g. 30/10 for bone mets instead of 8/1).

 

[medgator]

We all like to piss on protons in this forum, but consider the simple economics of the situation. We have a procedure (protons) which is reimbursed much more handsomely than another procedure (IMRT).

Can you really blame people for doing it? We are guilty of the same thing to a lesser degree (e.g. 30/10 for bone mets instead of 8/1).

You can argue 30/10 over 8/1 with data in appropriate patients. The same argument was used by proton advocates against imrt stating no randomized trials against 3DCRT. The cost differential though is like protons >>>>> imrt >> 3D. Plus with the new imrt codes coming down the pipe, 3D might actually start paying more 😉

I think the issue will eventually resolve itself when either 1) the data comes out or 2) protons become cost competitive with imrt

 

[xrthopeful]

I would add the spacer material (can't remember the trade name for it now) between the prostate and the rectum to allow for better rectal sparing. I would then treat with IMRT and IGRT, because proton beam therapy for prostate cancer is RIDICULOUS.

The SpaceOAR works great

 

[BobbyHeenan]

I think some blame has to go to ASTRO and the centers that have had proton therapy for decades now. No randomized trials done in that time and ASTRO really didn't take much of a stance when these new centers were popping up (sometimes in the same region). Instead, they chose to focus efforts on Urorads (that didn't seem to go anywhere) instead of turning the lens on our own specialty making some questionable claims.

I agree with some comments above - I think we're going to see reimbursement for proton come in line with IMRT until data shows clear clinical benefit. With proton facilities/machines becoming more affordable it may be possible to survive with IMRT-like reimbursements.

What's scary to me is that multiple centers are opening in the same cities/regions, is there volume to support this?

Probably not if you're using the technology/technique judiciously, but if your center is getting hammered by a competing proton center then it's not unreasonable to think you may want to look into getting your own proton machine to compete...especially if you're treating every prostate, L sided chest wall, and L sided APBI with protons, then there probably is volume for two competing proton centers. As mentioned, medicare pays for protons no questions asked, and a surprising number of private insurers do as well.

 

[medgator]

.

I agree with some comments above - I think we're going to see reimbursement for proton come in line with IMRT until data shows clear clinical benefit. With proton facilities/machines becoming more affordable it may be possible to survive with IMRT-like reimbursements.

Not for the legacy centers with $100 million+ investments to pay off. I suspect we will see some bankrupticies in the higher-cost "1st gen" centers if the smaller footprint cheaper proton centers get a foothold and reimbursement reaches parity for things like IMRT prostate.

ASTRO has already pushed IMRT codes into a "simple" (breast, prostate) and "complex" coding (everything else) which will potentially hit freestanding centers first especially "urorads" ones that ASTRO really hates (but eventually hospitals too, which ASTRO may or may not realize) next year. No reason to think protons for prostate gets cuts too (unlike protons for more solid indications like chordoma and peds).

 

[Gfunk6]

I would argue that using protons for prostate cancer is a bigger travesty than urorads, but that's just me.

 

[RadOncDoc21]

I think its the principal of urorads in which another specialty determines the radiation treatment (including designated rad oncs in urorad groups) versus the application of radiation. I do agree, protons for prostate at this time is not justified. I'm learning everyday, there is a lot of gray areas in our field and the application of radiation therapy. What one person might treat as palliation, another may see it as curable and likely would justify either more dose (more fractions) or even a more expensive technique (SBRT/SRS) that provides no benefit except maybe in local control.

Which is the worser of the two evils in this world?

 

[medgator]

A preferable approach over urorads would be multi-specialty ownership IMO by an independent medical group.

The alternative (which I have seen in practice) when urologists have no financial interest in radiation (and have questionable ethics) is lots of cryo, HIFU (out of the country at the patient's expense as it is NOT FDA approved), questionable prostatectomy (old pt, high Gleason score), etc. Sad but true.

 

[Gfunk6]

I think its the principal of urorads in which another specialty determines the radiation treatment (including designated rad oncs in urorad groups) versus the application of radiation.

It's not as if the Urologists keep a Radiation Oncologist chained in the vault to do their bidding. They require a willing co-conspirator. Also, ASTRO freely advertises Urorads jobs on their website making them a co-co-conspirator.

 

[medgator]

It's not as if the Urologists keep a Radiation Oncologist chained in the vault to do their bidding. They require a willing co-conspirator. Also, ASTRO freely advertises Urorads jobs on their website making them a co-co-conspirator.

Yup. ASTRO lets the urorads ship sail a decade ago and then somehow unleased the ASTRO PAC on them well after the ship had sailed, essentially hurting many free-standing centers in the process. The disparity between hospital-based and free-standing reimbursement continues to increase and facilitate hospital buyouts and consolidation much to the detriment of the free market/choice and price for payors and the system at large.

 

[Phantom1]

Yeah I think protons will lead to additional bad press for Radiation Oncology...

Anyway on to the next newest thing... Neutrino beam therapy! You have to sit on top of a mountain for years to get a single neutrino to interact with your prostate.. but once it does OH MAN! The prostate cancer is toast! Plus absolutely no dose to surrounding structures! The results are identical to active surveillance for very low risk prostate cancer!

 

[medicineradman]

i love how many of you hating on protons are using IMRT for equally questionable approaches, you just weren't in the field when the 3D --> IMRT transition was happening. But you'll happily take the IMRT reimbursements. I haven't used protons, but Ive read some very reasonable studies that do validate their use and have spoken with reasonable people who have use it daily for valid indications. The Luddites among us are toxic to our field. I know, I know we're talking about prostate here, but plenty of you act this way to every indication. Ive been to an institution that was clearly slighted that they didn't have protons. It was the saddest thing to see.

 

[xrthopeful]

i love how many of you hating on protons are using IMRT for equally questionable approaches, you just weren't in the field when the 3D --> IMRT transition was happening. But you'll happily take the IMRT reimbursements. I haven't used protons, but Ive read some very reasonable studies that do validate their use and have spoken with reasonable people who have use it daily for valid indications. The Luddites among us are toxic to our field. I know, I know we're talking about prostate here, but plenty of you act this way to every indication. Ive been to an institution that was clearly slighted that they didn't have protons. It was the saddest thing to see.

Stop so obviously trolling in every thread.


If you're gonna troll, do it right.

step up your game or simply don't come at all.

 

[Chartreuse Wombat]

i love how many of you hating on protons are using IMRT for equally questionable approaches, you just weren't in the field when the 3D --> IMRT transition was happening. But you'll happily take the IMRT reimbursements. I haven't used protons, but Ive read some very reasonable studies that do validate their use and have spoken with reasonable people who have use it daily for valid indications. The Luddites among us are toxic to our field. I know, I know we're talking about prostate here, but plenty of you act this way to every indication. Ive been to an institution that was clearly slighted that they didn't have protons. It was the saddest thing to see.

OK I will take the bait. Care to define what Luddite means in this context? The story/myth of Ned Ludd may not be apt to invoke but I think that you mean a Luddite to be someone "against technology". It should be self-evident that to be "against technology" precludes someone from practicing as a radiation oncologist. I don't know of any radiation oncologists who oppose technology in principle.

I do know many who are concerned that unbridled adoption of new technology without appropriate vigilance/testing is endangering the future of the specialty. The widespread adoption of IMRT for multiple indications is the most obvious example as you imply. Those that came of age in the late 1990's and owned their own machines had a very good decade or two but in the process our specialty has been singled out by the payors.

 

[thecarbonionangle]

i love how many of you hating on protons are using IMRT for equally questionable approaches, you just weren't in the field when the 3D --> IMRT transition was happening. But you'll happily take the IMRT reimbursements. I haven't used protons, but Ive read some very reasonable studies that do validate their use and have spoken with reasonable people who have use it daily for valid indications. The Luddites among us are toxic to our field. I know, I know we're talking about prostate here, but plenty of you act this way to every indication. Ive been to an institution that was clearly slighted that they didn't have protons. It was the saddest thing to see.

Like these? http://forums.studentdoctor.net/threads/protons-for-apbi.1025058/