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PROTON THERAPY: GO PUBLIC OR ELSE

I find that the public knows little about proton therapy, and the medical community is hesitant to embrace it. As a result, proton therapy has not blossomed the way one would expect, given its extraordinary potential. Here I present a solution: go public, to reach patients directly. Don't wait for referrals. The “or else” includes underperforming, operating in the red, or even bankruptcy.

DISAPPOINTING VOLUME

Most centers for which I have figures fail to meet their projections. One striking example is the recently bankrupt Scripps Proton Therapy Center in San Diego, California. (See blog article “High Numbers, Bankruptcies, and Fraud Impede Proton Therapy Developments”) Investors built the center and leased it to Scripps. It was developed by Advanced Particle Therapy LLC at very great cost, well over $200 million. Three of the four costly centers developed by APT have gone bankrupt. One will never be finished (Dallas), another (Atlanta) is in new hands and under construction but with an unbelievable burden of debt (they may issue $400 million in bonds, four times what a proton center currently costs), and one APT proton center seems to be doing okay (Maryland).

In the Scripps bankruptcy, the investors (California Proton Treatment Center) say Scripps was responsible, due to poor management and failure to reach projected volume. Scripps says it was saddled with unreasonable debt and overblown expectations. If I read it right, the new owners (California Proton Therapy Center, partnered with Proton Doctors Professional Corp.) may have paid $51 million for the center. (Varian, one of the investors, may have taken a hit for tens of millions of dollars.) Maybe the new center will do better now and take the center out of Chapter 11.

The proton therapy center at Hampton University, in Virginia, has acknowledged falling well short of their projections. An article in the Daily Press made this startling revelation. HU president William Harvey had predicted 2,000 patients annually, yet by their fifth anniversary in 2015, they had treated a total of 1,274 patients, less than 13% of their projection. Back in 2013, they billed Medicare for 212 "intermediate" treatments and 735 "simple" treatments. They claimed $2,700 to $3,200 respectively for each treatment, but Medicare allowed $815 to $847. Not the kind of income they were hoping for.

Another example. The ProCure Proton Therapy Center, a joint venture between CentraState Medical Center in Freehold, N.J., and Somerset, N.J.-based ProCure, a private-equity operator of three proton centers, has struggled to bring in enough patients. The center, which opened in 2012, had projected it would treat up to 80% of its patients for prostate cancer, but the actual number was close to 25%.  

Concern about flagging volumes led the center to form a partnership with the New York Proton Regional Center, a group of New York-based hospitals that plan to open their own proton center next year. As part of the agreement, physicians from Memorial Sloan-Kettering Cancer Center, New York University Langone Medical Center and three other hospitals will have staff privileges at the Somerset facility.

MEDRAYS LOWERS ESTIMATE

Think of it, proton centers operating at below both projections and capacity. Since pencil beam scanning can treat 80% of cancer types, it would seem that proton centers should be overwhelmed with business. But such is not the case. Why? Why? Why? In my book on proton therapy, I quote MEDRays Intell Proton Therapy World Report (2015) as saying 16,200 patients were treated with proton therapy in 2015, with a projected potential of 300,000 by 2030, only thirteen years from now.

But wait, in November, 2017, MEDRays decreased its projected demand for proton therapy centers by 25%. I think protons should be so flourishing they would need to increase their projections. Yet, in light of several factors , MEDraysintell is downgrading its proton therapy market projection from 1,200 proton therapy treatment rooms that were expected to be operational in 2030 to 900. This still represents a 12% annual growth from 2017 to 2030 and the need to open an average of more than 50 PT treatment rooms every year from 2018 to 2030. (See article at : http://medraysintell.com/News.html)

Fifty treatment rooms a year (worldwide) is still no slouch, but why did they need to make their revision? The following statistics were also taken from MEDRays which seems to be a dependable prognosticator. Their numbers for 2015 were extraordinary, showing a rapid growth for proton therapy. Here is a portion of their projection published that year:

The global particle therapy device market (mainly proton therapy devices) reached $750 million in 2015. The market growth has accelerated during the last five years, showing an average annual growth rate of 19 percent from 2010 to 2015. For the first time, the proton therapy world market is anticipated to reach over $1 billion in 2018, one year sooner than previously estimated. It is projected to reach between $3.5 billion and $6.6 billion by 2030, with 1,200 to 1,800 particle therapy treatment rooms open to patients worldwide.

The category of “particle therapy” includes several kinds of particles, but is mostly protons. Note also that this is a projection for devices (proton therapy equipment) and not patients. Still, those should be parallel. It seems in retrospect that 2015 represents a unique spike in the numbers and not the proper basis for estimating future growth. Fifty devices were ordered in 2015 and forty in 2016. Now, it appears, that downward trend is continuing, at least temporarily. Here is a quotation from an article in March, 2017. Authors Paul-Emmanuel Goethals and Dr. Richard Zimmermann are co-founders of MEDrays Intell, providing first-rate strategic intelligence in nuclear medicine, radiotherapy, proton therapy and brachytherapy.

ACCEPTANCE ISSUES

At equal investment levels, proton therapy would probably completely replace conventional radiotherapy in a large number of indications. Although the present issue is not related to the technological limitations, given that almost all improvements developed for radiotherapy could be adapted for proton therapy, it is clear that the difference in acceptance is a health care economic issue. . . . Patients have understood the differences and advantages of proton therapy and will definitely become the driving force for acceptance of this technology, which may take another 10 to 15 years.

This has long been my position. Acceptance of proton therapy is being resisted by purveyors of competing (and, alas, in some ways, inferior) technologies. Yes, x-rays have long served us and deserve recognition. But now, traditional radiologists are circling the wagons to defend themselves from proton therapy. Every patient a conventional radiologist refers to proton therapy is one he doesn’t treat, and therefore takes money from his (or her) pocket.

I have an acquaintance who went to M. D. Anderson in Houston with a brain tumor and was treated with conventional x-rays, which caused serious cognitive decline. After attending one of my presentations on proton therapy, my friend asked me why they hadn’t treated him with less damaging proton therapy, as M. D. Anderson has that capacity. I can only assume his doctor, who may have been unfamiliar with proton therapy, referred him to a conventional radiologist, who then treated him with his modality and kept proton therapy a secret.

It is inevitable that the increase in proton therapy will cause a decrease in other competing treatments. If I were a radiologist right now I would feel like a taxicab driver facing Lyft and Uber. Progress brings change, and leaves some people behind. Think of what cars did to the horse and buggy trades.

TRANSFER

In response to the announcement by MEDRays, Robert Zamenhof wrote the following response.

According to NIH statistics, the average annual increase in cancer rate over the next two decades will be 2.8%-3.0%. This means that approximately 12%-3.0% = 9% of these putatively new proton facilities each year would be treating 'transfer' patients from conventional radiation therapy to proton therapy. Is there a consensus that this could possibly occur? I am skeptical about the 12%/year increase in proton facilities being able to find sufficient patients to treat. I am a great supporter of proton treatment from a clinical perspective, so I would love to be proved wrong!

Transfer. That’s the word I was lacking. X-rays have a substantial head start. They have been around for decades, have continued to upgrade their technology, are supported by innumerable studies, and present a formidable barrier to overcome. Globally there may be around 200 proton therapy rooms, versus more than 14,000 x-ray facilities. Protons as a marketshare comes in at 0.6% of all patients needing radiotherapy. Even with the prediction of 900 centers and 300,000 patients by 2030, that would still represent less than 7% of the market.

Frankly, right now, 300,000 looks extremely optimistic. So does 900 centers. Proton therapy is facing more issues than resistance from competing modalities. The number of bankruptcies and under-performances may discourage some institutions, which will wait to see how things level out. You don’t rush into spending $100 million, or even half of that. (X-ray equipment costs around $5 million, meaning many clinics can afford to have several, but they can’t afford proton equipment.) Institutions that waited a few years can now built a center at a third of the previous cost, saving hundreds of millions of dollars. Some interested buyers may continue to wait until demand increases and miniaturization brings lower equipment cost.

DIRECT ADVERTISING

I continue to see articles that say protons are overpriced and aren’t much better than the alternatives. They say protons are hyped through exaggerated marketing. If only that were so. When I found my United Healthcare policy wouldn’t cover proton therapy for my prostate cancer, I began to contact proton centers to ask what my out-of-pocket cost would be. The University of Florida in Jacksonville said $134,000 whereas for the same treatment, Provision in Knoxville, Tennessee, quoted $93,000. Wow, just by shopping around I could save $41,000. But then they asked me if I am on Medicare, which is indeed the case (I’m 73). They then made a statement that changed everything. If I was willing to be tracked for the rest of my life to record the success of proton therapy, Medicare would pay 80% of the cost, regardless of my insurance.

Of course I agreed and I went there for my treatment (September-October, 2016). They were the only center that offered me that option. (Also on their registry is Ackerman Cancer Center in Jacksonville, Florida, and soon, Texas Center for Proton Therapy in Irving (near Dallas). Then, they got United Healthcare to pay the other 20%. I think they should have billboards everywhere asking, “On Medicare? We can treat you with proton therapy if you joni our registry.” Too much hype? No, I think not enough.

The answer to increasing business, I believe, is direct advertising from proton centers (or organizations representing them) to the public. At Provision, 85% of the patients are self-referred. They had to find out about proton therapy on their own. That statistic is what has driven me to write books and make websites, so the public can learn about protons.

I recently went through Love Field Airport in Dallas and noticed a large electronic billboard display for Texas Center for Proton Therapy. It scrolled through several versions, with different people and different cancers. Here's one of them. Note how they call themselves the state's most advanced proton therapy center, as opposed to M. D. Anderson in Houston.

I was pleased. The lighted free-standing sign was very visible by thousands of people. But still, how many paid any attention in their rush to get a plane? Provision advertises in local media suggesting the viewer (or listener) would do well to obtain a second opinion before making the decision about which treatment is best for their cancer. Very subtle.

The pharmaceutical industry is a model of what I am suggesting. They flood both electronic and print media with their ads. Even though the patient can’t go out and buy prescription drugs, they are instructed to “ask their doctor” about it. Perhaps a similar approach would give a boost to proton therapy. Of course, they don't have the big bucks of Big Pharma.

HOPE

I don’t believe the prospects are hopeless. Think of when FOX news first started, promising to challenge the big three, ABC, CBS, and NBC. I laughed at their chutzpa. Now they are a force to be reckoned with (alas). And all of those radiologists out there? It isn’t such a leap to transfer to the proton side. The technologies have much in common. There is a technology promoted by ProTom International that can build a compact proton therapy unit into the space of two LINAC rooms (x-rays) at an exceptionally affordable price. They are just completing their first installation at Mass General in Boston. Radiology clinics might soon be able to include protons in their practice. Then maybe they wouldn't object to it so much.

So, join the crusade to get out the word. It may be the only way protons will receive the recognition and exposure they deserve. I have a bumper sticker (see photo) that may cause some people to wonder why I like part of an atom. If only they knew.

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Here again are my other two related websites:

www.ProtonTherapyBook.com
This is for Best Prostate Cancer Treatment: Proton Beam Therapy and other books I have or soon will have written. It has updates and additional information, photos, and more.

www.proton-therapy-centers.com
This site has an up-to-date list of proton therapy centers in operation in the United States, as well as a number planned or under construction. Currently 27 centers listed as operational and 16 in the planning or construction stages.

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