ASTRO'S New Model Policy Supports Proton Therapy for Pediatrics

The American Society for Radiation Oncology (ASTRO) has issued a new Model Policy for proton beam therapy (PBT) that details which cancer diagnoses meets ASTRO's evidence-based standards and should be covered by private insurers and Medicare.  Developed by leading radiation oncologists and medical physicists, including significant input from expert representatives in proton therapy, this Model Policy supports PBT coverage for appropriate patients and identifies areas where coverage with evidence development and further research are needed.  

PBT's reduced radiation dose to healthy tissues is attractive because it can reduce side effects for patients, which potentially increases their quality of life. To date, scientific evidence exists confirming that PBT is particularly useful in a number of pediatric cancers, particularly those in the brain, as well as for certain adult cancers such as ocular melanoma.

In identifying and describing appropriate use of proton-beam therapy, the policy lists four circumstances when use of the technology is reasonable (and most pediatric cases would then qualify):

1.      Target volume is close to a critical structure, requiring a steep dose gradient outside the target to limit the structure's exposure.

2.      A decrease in dose inhomogeneity in a large treatment volume is required to avoid an excessive "hotspot" within the target volume.

3.      Use of photon-based therapy carries an increased risk of clinically meaningful normal-tissue toxicity.

4.      The same area or an adjacent area has been previously irradiated, increasing the need for sculpting to limit the cumulative radiation dose.

 

Ama(yo)zing Mayo Clinic Visit

I was honored to be asked to speak at Mayo Clinic last week regarding pediatric proton therapy and the obstacles parents face.  It was hard not to be impressed upon arrival to Rochester as Mayo Clinic and its affiliates seem to occupy most of the downtown.  With some 35,000 employees the town is a hustle and bustle of medical professionals and patients.  The underground Subway system that is not a mechanical subway, but rather a collection of underground walkways, restaurants and shops allows you to go from most downtown hotels to the clinic without ever going outside or needing a car.  When I walked around town, there were numerous restaurants and activities within close distance of the clinic.   I saw people from all over the world and I thought how lucky are we to have great medical care right here in Rochester, Minnesota.   Being a huge Steelers fan, I tried to ignore the town’s obsession with the Vikings – though a good rivalry.

I commend Mayo proton for preparing to treat pediatrics and having the guts to hear from a person like me how hard work it is.  So with the latest in technology, we were able to broadcast my slides and myself all the way to Phoenix and other parts of the center.  My main message included parents (many nontraditional) being high maintenance and the cancer children coming with siblings, grandparents and a lot of other challenges.   I spoke a lot about insurance challenges and what a disaster it is that insurers often hinder a child from receiving proton therapy.  

I then got to tour the new proton center!  There was a lot of excitement because the beam was going live that day.  I loved the design, very bright and crisp, with keeping in mind workflow and efficiency with anesthesia prep and recovery.   All my hosts listened with open ears as I commented from my standpoint.   I just know parents and the kids are loungers and take more space then really necessary (maybe there is something about controlling the corner of a waiting room.)  I wished my best idea wasn’t a new slushie machine, though I can’t imagine anything more fun for a kid coming out of anesthesia or for that matter a grumpy adult.  I had a chance to talk to many different groups that will be caring for the children and all had a focus on how their area could make the experience positive and fun for the kids.  I left that day thinking this is going to be a truly great center keeping with the high expectations one expects from Mayo clinic.  Besides having some of the top pediatric experts in the world – they have people that care enough to ask and listen.  Special thanks to Becky and Shari for making my trip a wonderful and memorable experience!

 

Proton therapy is a cost-effective treatment for pediatric brain tumor patients

Atlanta, September 22, 2013

Due to decreased side effects, it may also be cost-saving

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PDF of press release and abstract

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Proton therapy, an external beam radiotherapy in which protons deliver precise radiation doses to a tumor and spare healthy organs and tissues, is cost-effective in treating medulloblastomas, fast-growing brain tumors that mainly affect children, when compared to standard photon radiation therapy, according to research presented today at the American Society for Radiation Oncology’s (ASTRO’s) 55th Annual Meeting.

The study used a first-order Monte Carlo simulation model to examine a population of 18-year old survivors of medulloblastoma brain tumors who were assumed to have been diagnosed at age 5 and at risk of developing 10 adverse health events, including various hormone deficiencies, coronary artery disease, congestive heart failure, ototoxicity, secondary malignant neoplasm and death. Primary institutional information on the cost of investment and Medicare data regarding the cost of management of the various adverse health conditions, in addition to peer-reviewed publications analyzing incidence of side effects were used in the simulation model to perform a cost-effectiveness analysis comparing proton and photon therapy from the societal perspective. Outcomes were measured in incremental cost-effectiveness ratios, with costs measured in 2012 U.S. dollars (USD), and effectiveness measured in quality-adjusted life years (QALYs). A societal willingness-to-pay (WTP) threshold of $50,000/QALY was the benchmark.

The clinical benefits of proton therapy have been recognized in reducing side effects when compared to photon therapy, but the significant expense of building and maintaining proton facilities and the high treatment costs have been areas of concern. The study’s results demonstrate that by avoiding years of costly side effects, proton therapy can be cost-effective for children with medulloblastoma. Using current risk estimates and data on required capital investments, proton therapy for pediatric medulloblastoma treatment was not only cost-effective compared to standard photon radiation, but also found to be cost-saving in many simulations.

Results from the base case analysis showed that due to the prevention of side effects, proton therapy was cost-saving. In sensitivity analyses, proton therapy strongly remained the more appealing treatment, in part due to decreased risks of hearing loss, secondary malignancy and heart failure, resulting in cost-savings in more than 95 percent of simulations.

“We believed that proton therapy might prove to be cost-effective in treating pediatric brain tumors, and we were intrigued that it also proved to be cost-saving in the base case and in almost all of the sensitivity analysis simulations,” said Raymond Mailhot Vega, MD, MPH, the presenting author of the study; a resident at Mount Auburn Hospital, the teaching hospital of Harvard Medical School; and a 2014 radiation oncology resident at New York University’s Langone Medical Center. “Proton therapy might prove to be both cost-effective and cost-saving for other malignancies, too, and consequently, more cancer patients may benefit from proton therapy.”

The abstract, “Cost-Effectiveness of Proton Therapy Compared to Photon Therapy in the Management of Pediatric Medulloblastoma,” will be presented in detail during a scientific session at ASTRO’s 55th Annual Meeting at 1:45 p.m. Eastern time on Sunday, September 23, 2013. To speak with Dr. MailhotVega, please call Michelle Kirkwood on September 22-25, 2013, in the ASTRO Press Office at the Georgia World Congress Center at 404-222-5303 or 404-222-5304, or email Michelle Kirkwood.

ASTRO’s 55th Annual Meeting, held in Atlanta, September 22-25, 2013, is the premier scientific meeting in radiation oncology and brings together more than 11,000 attendees including oncologists from all disciplines, medical physicists, dosimetrists, radiation therapists, radiation oncology nurses and nurse practitioners, biologists, physician assistants, practice administrators, industry representatives and other health care professionals from around the world. The theme of the 2013 meeting is “Patients: Hope • Guide • Heal” and will focus on patient-centered care and the importance of the physician’s role in improving patient-reported outcomes and the quality and safety of patient care. The four-day scientific meeting includes presentation of four plenary papers, 363 oral presentations, 1,460 posters and 144 digital posters in 70 educational sessions and scientific panels for 19 disease sites/tracks. Keynote speakers include: William B. Munier, MD, Director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality; Darrell G. Kirch, MD, President and CEO of the Association of American Medical Colleges; James Cosgrove, PhD, Director, the U.S. Government Accountability Office; Otis W. Brawley, MD, Chief Medical Officer of the American Cancer Society; and Peter Friedl, MD, PhD, of St. Radboud University Nijmegen Medical Centre at the University of Nijmegen and MD Anderson Cancer Center.

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