What to know about proton therapy, the costly and controversial cancer radiation treatment

More than three decades after the U.S. Food and Drug Administration approved proton beam radiation therapy, the benefits of the costly treatment compared to cheaper traditional radiation is still unclear for many types of cancers.

Both work to kill cancer cells. Both are sophisticated forms of radiation that have advanced technologically over the past 30 years. Both can cause other health problems, particularly as patients age. So far, there is limited research of the highest quality — randomized clinical trials — comparing the two treatments.

Penn Medicine opened a new proton therapy center in Lancaster in December and is poised to open another center in South Jersey in the coming weeks in partnership with Virtua Health. Penn, along with other researchers across the country, is conducting clinical trials that aim to help settle an ongoing debate in health care: Which type of radiation works better to treat cancer, with fewer side effects, and preserve life?

» READ MORE: Penn Medicine is going all in on proton therapy, a costly treatment that is unproven for most common cancers

Here’s what cancer patients in our region might want to know:

Proton beam therapy is a type of radiation that uses a different ray than “regular” (X-ray) radiation treatments, which use photons. The proton beam is precise, and as such, the treatment can help destroy cancer cells near or within sensitive organs, like the brain and spinal cord, while limiting radiation exposure to healthy tissue. The highly targeted beam hits the cancer — and stops. Proton therapy centers can cost anywhere between $30 million to $200 million to build, depending on the number of treatment rooms.

The photons of conventional radiation release energy as they enter and exit the body. However, technological advances have helped minimize the resulting “scatter radiation.” Today’s treatment uses complex technology, called “intensity-modulated radiation therapy,” or IMRT, to harness multiple converging beams to better focus the damaging rays. Radiation therapy machines that use X-rays to fight cancer can cost about $3 million each.

Sometimes. Medicare, the government insurance for people 65 and older, typically covers proton therapy, although it costs taxpayers about double the price of IMRT: Roughly $1,300 for each proton treatment session versus less than $600 for the standard radiation using photons, or IMRT. Both treatments are daily, and could continue for roughly five to nine weeks. That means the difference in cost between the treatments can rack up to $30,000.

Private insurance companies generally don’t cover proton radiation for the most common types of cancers, such as breast, prostate and lung. They will sometimes cover it for rare, hard-to-treat cancers, particularly spinal cord and brain tumors that can’t be fully removed with surgery. Insurers will typically cover proton treatment for children with cancer because there’s medical consensus that it’s less harmful to a developing brain and body.

Coverage may vary by insurer and cancer center. Penn Medicine, for instance, has agreements with three private insurers in the region — Independence Blue Cross, Horizon Blue Cross Blue Shield of New Jersey and Aetna — to cover proton therapy. For patients who participate in proton therapy research, Penn bills for the treatment at the same rate as conventional radiation, according to James Metz, who chairs Penn’s radiation oncology department.

» READ MORE: For breast cancer patients, Penn researchers are comparing costly proton therapy with standard radiation

It’s mixed so far. Some studies, though limited, suggest better outcomes with proton therapy. Other research does not.

For example, Penn co-published data showing that for early-stage prostate cancer, conventional IMRT radiation was just as good as proton beam therapy, according to Penn radiation oncologist Justin Bekelman.

Given that finding, Bekelman said it’s reasonable to choose the cheaper option.

“When we have two treatments that are similar in terms of cure rates and side effects, in general, we should use the one that is associated with less out-of-pocket costs and less spending,” Bekelman said. “Sometimes people might still have a preference for one or the other, and that’s fine, too.”

Another study in patients with 11 different types of advanced-stage cancer found that Penn patients treated with both chemotherapy and proton therapy were less likely to suffer severe side effects, such as dehydration, that required hospitalization, than those who received chemotherapy and traditional IMRT radiation. There was no difference in how long patients lived.

Researchers noted that the retrospective study did not provide proof that proton therapy causes fewer side effects, but raises “the tantalizing possibility that the higher up-front cost of proton therapy may be offset by cost savings from reduced hospitalizations and enhanced productivity from patients and caregivers.”

In an editorial that accompanied the study, Yale’s Henry Park and James Yu wrote that “the evidence needed to truly justify the expenses of proton therapy … will need to come from phase 3 randomized clinical trials.”

Those trials are underway.