Radiation Oncology/Protons/Economics

Economic Issues Related to Proton Therapy

• Lyon, France; 2010 PMID 20452693 -- "Simulating demand for innovative radiotherapies: An illustrative model based on carbon ion and proton radiotherapy." (Pommier P, Radiother Oncol. 2010 May 7. [Epub ahead of print])
  • Probabilistic model developed to allocate patients to the optimal treatment strategy and facility
  • Conclusion: Modelling patient recruitment may aid decision-making when planning new and expensive treatments

• Maastricht, The Netherlands
  • Cost Effectiveness; 2008 PMID 18707784 -- "Cost-effectiveness of particle therapy: Current evidence and future needs." (Pijls-Johannesma M, Radiother Oncol. 2008 Nov;89(2):127-34. Epub 2008 Aug 15.)
    • Literature review of cost and cost-effectiveness of proton therapy
    • Outcome: Literature scarce, non-comparable, and not performed according to standard health technology assessment criteria
    • Conclusion: Model-based economic evaluations may help gain evidence-based insight into cost-effectiveness
  • Facilities; 2010 PMID 20106540 -- "How costly is particle therapy? Cost analysis of external beam radiotherapy with carbon-ions, protons and photons." (Peeters A, Radiother Oncol. 2010 Jan 25. [Epub ahead of print])
    • Estimate of capital and operational costs, cost per fraction, and 4 tumor-specific treatment costs. Facilities: carbon/proton facility, proton only, and photon only
    • Outcome:
      • Capital costs: Euro 139 M vs 95 M vs 23 M
      • Operational costs: Euro 37 M vs 25 M vs 10 M
      • Cost per fraction: Euro 1,128 vs 743 vs 233
    • Conclusion: Costs evaluated
  • NSCLC; 2010 PMID 20303217 -- "The cost-effectiveness of particle therapy in non-small cell lung cancer: Exploring decision uncertainty and areas for future research." (Grutters JP, Cancer Treat Rev. 2010 Mar 17. [Epub ahead of print])
    • Markov model. Comparative treatments carbon-ion, protons, conventional RT, and SBRT for Stage I NSCLC
    • Outcome: For inoperable NSCLC, Carbon cost euro 67,257 per QALY compared to SBRT; both carbon and SBRT dominated protons and conventional RT. For operable NSCLC, SBRT dominated carbon ion. Considerable uncertainity in estimates
    • Conclusion: It is recommended not to adopt particle therapy in Stage I NSCLC until more evidence is available

• Fox Chase; 2007 PMID 17704408 -- "Is proton beam therapy cost effective in the treatment of adenocarcinoma of the prostate?" (Konski A, J Clin Oncol. 2007 Aug 20;25(24):3603-8.)
  • Markov model. Cost-effectiveness evaluation of 91.8 CGE proton beam vs. 81 CGE photon IMRT, using cost, bNED, utility data
  • 15 year model: 70 year old: cost of protons $63,500 vs. IMRT $36,800; 60 year old: protons $65,000 vs. photons $39,400. Incremental cost/QALY 70-year old $63,6000 and 60-year old $55,700
  • Conclusion: Assuming 10 Gy additional dose-escalation, proton beam not cost-effective for most patients
  • Editorial (PMID 17704400): PT legitimate form of EBRT for prostate cancer, but if dose escalation cannot be achieved over existing therapies, economic utility relies on clear and meaningful difference in quality of life. This area should be investigated urgently

• Yale; 2007 PMID 17500444 -- "Point/counterpoint. Proton therapy is too expensive for the minimal potential improvements in outcome claimed." (Schulz RJ, Med Phys. 2007 Apr;34(4):1135-8.)

• ENLIGHT; 2005
  • Workgroup reports

• Sweden; 2005 PMID 15885828 -- "Economic evaluation of proton radiation therapy in the treatment of breast cancer." (Lundkvist J, Radiother Oncol. 2005 May;75(2):179-85.)
  • Markov model simulation, 55 year old patient with left-sided BCA
  • Outcome: Euro 67,000 cost per QALY gained; better if high risk cardiac patients treated
  • Conclusion: Proton therapy for BCA can be cost-effective if appropriate risk groups are chosen
  • Editorial (PMID 15890422): From global health care point of view, cost of proton therapy is not outrageous at all

• Sweden Acta Oncol Issue; 2005
  • Editorial; 2005 PMID 16332585 -- "Swedish protons." (Goitein M, Acta Oncol. 2005;44(8):793-7.)
    • Editorial for an issue of Acta Oncologica dedicated to protons
  • Eligible patients; 2005 PMID 16332591 -- "Number of patients potentially eligible for proton therapy." (Glimelius B, Acta Oncol. 2005;44(8):836-49.)
    • Estimate of number of patients in Sweden suitable for proton beam. Assume facility focused on randomized and prospective studies to show benefit
    • Outcome: 2200-2500 patients annually eligible with sufficient therapeutic benefit; ~15% of all patients undergoing RT annually
  • Cost-effectiveness; 2005 PMID 16332592 -- "Proton therapy of cancer: potential clinical advantages and cost-effectiveness." (Lundkvist J, Acta Oncol. 2005;44(8):850-61.)
    • Markov simulation. Cost per QALY Euro 10,130. If value of QALY set at Euro 55,000 then total annual benefit to treating 925 patients is Euro 20.8 million
    • Conclusion: Investment in a proton facility may be cost-effective
  • Breast; 2005 PMID 16332597 -- "The potential of proton beam radiation therapy in breast cancer." (Bjork-Eriksson T, Acta Oncol. 2005;44(8):884-9.)
    • Estimates for ~300 breast cancer patients annually, out of 3425 total
  • GI; 2005 PMID 16332599 -- "The potential of proton beam radiation therapy in gastrointestinal cancer." (Ask A, Acta Oncol. 2005;44(8):896-903.)
    • Estimate for 345 patients, mainly nonresectable rectal/esophageal, and liver cancers
  • GU/GYN; 2005 PMID 16332598 -- "The potential of proton beam radiation therapy in prostate cancer, other urological cancers and gynaecological cancers." (Johansson B, Acta Oncol. 2005;44(8):890-5.)
    • Estimates for ~300 prostate patients and ~50 GYN patients annually
  • Head & Neck; 2005 PMID 16332595 -- "The potential of proton beam radiation therapy in head and neck cancer." (Ask A, Acta Oncol. 2005;44(8):876-80.)
    • Estimate ~300 patients annually with H&N cancers
  • Intracranial/Ocular; 2005 PMID 16332593 -- "The potential of proton beam radiation therapy in intracranial and ocular tumours." (Blomquist E, Acta Oncol. 2005;44(8):862-70.)
    • Estimates for CNS and ocular tumors, 130-180 total per year
  • Lymphoma/Sarcoma; 2005 PMID 16332601 -- "The potentials of proton beam radiation therapy in malignant lymphoma, thymoma and sarcoma." (Bjork-Eriksson T, Acta Oncol. 2005;44(8):913-7.)
    • Estimates for lymphoma ~20 patients/year, and sarcoma (not skull base) ~40/year
  • Medulloblastoma; 2005 PMID 15637691 -- "Cost-effectiveness of proton radiation in the treatment of childhood medulloblastoma." (Lundkvist J, Cancer. 2005 Feb 15;103(4):793-801.)
    • Markov simulation, children age 5 followed for tumor control and adverse events
    • Outcome: Proton therapy 23,600 cost saving, 0.68 additional QALY per patient. Biggest benefit due to reduction in IQ and GHD loss
    • Conclusion: Proton therapy can be cost-effective and cost-saving compared with conventional RT
  • Palliation/Reirradiation; 2005 PMID 16332602 -- "The potential of proton beam radiation for palliation and reirradiation." (Bjork-Eriksson T, Acta Oncol. 2005;44(8):918-20.)
    • Estimates for palliation and irradiation; ~100 palliative treatments and ~150 re-irradiation treatments might benefit
  • Pediatric; 2005 PMID 16332594 -- "The potential of proton beam therapy in paediatric cancer." (Bjork-Eriksson T, Acta Oncol. 2005;44(8):871-5.)
    • Estimates 80-100 pediatric cases/year, ~20 with medulloblastoma
  • Thorax; 2005 PMID 16332596 -- "The potential of proton beam radiation therapy in lung cancer (including mesothelioma)." (Bjelkengren G, Acta Oncol. 2005;44(8):881-3.)
    • Estimate ~350 patients with lung cancer and ~20 patients with mesothelioma annually may benefit from proton beam therapy

• France; 2004 PMID 15974560 -- "A "one-day survey": as a reliable estimation of the potential recruitment for proton- and carbon- ion therapy in France." (Baron MH, Radiother Oncol. 2004 Dec;73 Suppl 2:S15-7.)
  • Survey. Performed in 1 day, all new starts in 5 RT centers
  • Outcome: 77/532 (14%) of patients might be potential candidates for hadrontherapy

• MedAustron, Austria
  • 2004 PMID 15971304 -- "Epidemiological aspects of hadron therapy: a prospective nationwide study of the Austrian project MedAustron and the Austrian Society of Radiooncology (OEGRO)." (Mayer R, Radiother Oncol. 2004 Dec;73 Suppl 2:S24-8.)
    • Nationwide survey, over period of 3 months. See below for full detail
    • Outcome: Potential patients 2044 per year, which is 13% of irradiated patients and 6% of newdly diagnosed cancer patients
    • Conclusion: There is a place for hadron therapy facility in Austria
  • 2004 PMID 15971305 -- "The med AUSTRON/OGRO patterns of care study on radiotherapy indications in Austria." (Mock U, Radiother Oncol. 2004 Dec;73 Suppl 2:S29-34.)
    • National survey, 12 RT departments in Austria, over period of 3 months
    • Outcome: 3783 patients registered. Indications reviewed (breast CA ~26%, urologic tumors ~12%, bone metastases ~10%)
    • Conclusion: Most common indications established, variations among departments observed
  • 1999 PMID 10394411 -- "Cancer epidemiology and patient recruitment for hadron therapy." (Engles H, Strahlenther Onkol. 1999 Jun;175 Suppl 2:95-9.)
    • Review of cancer incidence; estimate of potential patients suitable for hadron therapy
    • Conclusion: Sufficient and adequate recruitment can be expected

• CNAO Italy
  • 2004 PMID 15971303 -- "Medical aspects of the National Centre For Oncological Hadrontherapy (CNAO-Centro Nazionale Adroterapia Oncologica) in Italy." (Krengli M, Radiother Oncol. 2004 Dec;73 Suppl 2:S21-3.)
    • Review of Centro Nazionale Adroterapia Oncologica (CNAO) rationale
    • Updated estimate of 10-15% irradiated patients would benefit from ion therapy
  • 1998 PMID 9620246 -- "Number of potential patients to be treated with proton therapy in Italy." (Orecchia R, Tumori. 1998 Mar-Apr;84(2):205-8.)
    • Estimate of patients who might benefit from proton therapy in Italy.
    • Outcome: Category A (clear benefit) = 825 patients. Category B (potential benefit) = >10,000
    • Conclusion: ~16% of irradiated patients might be candidates for proton therapy

• Switzerland; 2003 PMID 12602563 -- "The relative costs of proton and X-ray radiation therapy." (Goitein M, Clin Oncol (R Coll Radiol). 2003 Feb;15(1):S37-50.)
  • Estimated costs for both 2-room proton and photon based facilities, both currently and in the future with improved efficiency and costs.
  • Cost estimate: facility proton 62.5 M euro vs. linac 16.8 M euro (3.7x). Per fraction 1025 euro vs. 425 euro (2.4x). Future costs could be 370 euro vs 230 euro (1.6x)
  • Conclusion: Ratio of costs is ~2.4x at present, and could come down to 2.1x and even 1.7x over the next 5-10 years