Price of protons

Posted by on Thursday, August 27th, 2015

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With the cost of cancer treatment making constant headlines and hundreds of million of dollars being invested into new proton therapy centers around the world, it’s tempting to believe some experts who tout the cancer treatment as the latest contributor to healthcare’s skyrocketing costs.

That’s just not true, says Scott Warwick, vice president for strategic initiatives and program development for Provision Healthcare and chair of the National Association for Proton Therapy.

“People look at the cost of some proton therapy centers being built and assume because it’s so much more expensive to set up than conventional radiation that it is directly reflected in the cost to the patient,” he says. “That’s not exactly the way it works.”

The majority of proton therapy centers are freestanding rather than connected to medical centers. Medicare sets the rate it will pay for the service including the facility, equipment, personnel costs, supplies, geographic location, insurance and other direct and indirect expenses. It is not based solely on the price tag of the center and equipment. Private insurance companies individually negotiate with providers like Provision based on the rates Medicare sets for that facility.

Additionally, many of the centers receive significant philanthropic gifts to support the construction of the facility and purchase of the equipment. The Mayo Clinic, for example, received more than $100 million to support its new proton facility. This substantially reduces the cost to develop a proton therapy center.

And while initially proton therapy was more expensive than the conventional radiation it competed with, newer methods of delivering the therapy have reduced the number of treatments required and, thus, the cost of service.

Hypfractionation refers to the method of treating patients with the same prescribed dose of radiation with two-thirds to one-third treatments. Because of proton therapy’s ability to precisely target tumors with limited exposure to surrounding tissues, there are less side effects with treatment, which make it the ideal modality for hypofractionation.

For example, a study at MD Anderson Cancer Center showed a hypofractionated protocol for breast cancer cost $13,833 compared to the $19,599 cost of conventional radiation. Medicare reimbursement rates for hypofractionated treatment of prostate cancer show the cost of proton therapy at $26,050 with the cost of conventional radiation at a comparable $24,420. At Provision, prostate patients who choose hypfractionation cut their number of treatments from 39 to 20.

Harder to quantify are the cost savings from the reduced side effects and reduced radiation exposure proton therapy offers. For head and neck cancers, proton therapy reduces patient weight loss and the need for feeding tubes—factors that dramatically reduce the gap between proton and x-ray therapy, particularly toward the end of treatment. Proton therapy reduces the risk of pneumonitis, esophagitis, heart disease and secondary cancers due to radiation exposure for lung cancer patients. Recent studies show women treated for breast cancer using conventional radiation receive damaging doses to the heart and lungs. Pediatric patients see a long list of physical and neurological benefits from proton therapy.

Another MD Andersen study compared the cost of proton therapy and radiation in the case of patients with head and neck cancer, concluding the proton therapy cost just 6 percent more than intensity-modulated radiation therapy when taking into account the healthcare costs associated with weight loss, feeding tubes placement and resulting treatment re-planning and re-simulation because of greater side effects associated with IMRT.

This impact on a patient’s life after cancer is known as “quality-adjusted life years,” but Warwick agrees that’s difficult to quantify.

“It is difficult to put a price on improving someone’s quality of life,” he says. “It is a very inexact science and often varies in the eye of the beholder. It is easy to minimize having a feeding tube placed into your abdomen until you’re the one having the procedure performed.”

And yet, people—and their health insurance companies—are willing to pay for much costlier chemotherapy treatments to prolong life, if only for a few weeks or months. He cites an example of a drug for metastatic prostate cancer, shown to extend life on average by four months. The cost: $90,000.

“That’s double the cost or more for most proton therapy cases,” he says. “And this drug receives robust coverage from most commercial insurance payers, even though it is not even used to cure the cancer.”

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Provision patient has pre-treatment health makeover

Posted by on Friday, August 21st, 2015

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When Hal Livergood came to Provision for treatment of his prostate cancer last February, he discovered he was living just two miles from the only proton therapy center in the Southeast. He was impressed by the brand new facility—“like coming into a resort,” he says. His doctor and personal research told him protons were the best treatment option for his disease.

There was just one problem.

“Dr. Fagundes said, ‘You need to lose weight,’” Livergood says, of Provision Center for Proton Therapy’s medical director, Marcio Fagundes. Otherwise, treatment would not be an option.

At 455 pounds and faced with a life-threatening disease, he wasted no time.

He met with nutritionist Casey Coffey at Provision Health and Performance, adopted a clean, real, whole foods diet and began exercising two hours a day—cardio in his home pool spa plus a strengthening regime.

“I lost 50 pounds in just a few months,” Livergood says. By the time he was ready to start proton therapy, he had lost 90 pounds in all. His edema disappeared. He felt better.

“Between Casey and Dr. Fagundes, they’re saving my life in more ways than one,” he says.

Livergood’s case may have been extreme, but early research is showing that tackling lifestyle changes prior to treatment can help improve long-term outcomes for cancer patients.

A recent article in the Washington Post documented this “pre-habbing” phenomenon, citing a study in the journal Anesthesiology that showed patients diagnosed with colo-rectal cancer who adopted a program of exercise, nutritional counseling and relaxation four weeks prior to surgery experienced better recovery than those with eight weeks of rehabilitation following the procedure. Research findings for non-cancer-related operations indicate the same, although more study is needed to determine the broader impacts of pre-treatment lifestyle interventions.

Some research shows a positive impact of healthy lifestyle choices during cancer treatment. For example, exercise has been shown to help alleviate fatigue in breast cancer patients and relaxation exercises help improve mental health and sleep patterns for cancer patients. Other research shows improved immune response and response to cancer treatment with particularly dietary supplementation or interventions.

In spite of the lack of studies into the impact of diet on cancer treatment outcomes, Coffey says “sugar is the only fuel cancer can survive on,” so she advocates a diet in which her clients that reduces carbs and focuses on proteins and whole, unprocessed foods. She also works with patients to identify foods they enjoy and build a plan around making lifestyle change workable.

“I had lost thousands of pounds over my lifetime,” Livergood says, with diets ranging from liquid to fat free. But after learning about the chemical reactions of the food in the body, necessary balance between protein, carbohydrates and fat he’s made changes for the long-term. And he says he doesn’t even want the junk food he once ate on a regular basis.

“The goal is to control carbohydrate intake.  We need a balance in nutrients, protein, fat and carbohydrate,” Coffey says.

When patients understand the way food affects their health and make changes for the right reasons, “the desire is just not there,” she says. “”You also have that thought process, is it really worth it?”

“’If it’s killing me,’ I think, ‘I don’t want to eat it,’” Livergood adds.

Support at home has also been crucial, and Livergood’s wife, Nancy Lee, has been there every step of the way—losing 18 pounds in the process herself. Coffey took her to Trader Joe’s, patient consults frequently include a grocery shopping trip, showing her products that support their new lifestyle.

“It’s one thing to sit in a room with somebody,” Coffey says. “I say, ‘I want you to start shopping like you would normally shop. What does it look like when you’re trying to implement something? We are so programmed to our own pattern of shopping and eating, and it’s eye opening for patients and their families to start looking at food in a new way.”

Now that he’s in treatment for his prostate cancer, Livergood says he is suffering through a low residue diet, a low-fiber regimen required for prostate cancer treatment that requires patients to cut out legumes and whole grains and reduce dairy consumption. The treatment and related hormone therapy have also left him feeling fatigued and limited his exercise routine.

Once he’s done, however, he plans to tackle the weight loss anew.

“I’ve got another 120 pounds at least to lose,” he says. “I’ve got to stay on the program.”

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Kentucky patients flock to Provision

Posted by on Friday, August 14th, 2015

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A growing number of Kentuckians are coming to Provision Healthcare for cancer treatment and leaving as advocates of proton therapy in their home state.

More than 20 patients from the Bluegrass State have completed treatment at the Provision Center for Proton Therapy, and the state serves as one of the largest sources of patients next to Provision’s home state of Tennessee. Patients have come to receive treatment for prostate, breast and lung cancer and lymphoma and have included two pediatric patients suffering from brain tumors.

Proton therapy, for me, was a wonderful discovery,” said Glenn Ross, owner of Investment His Way in Elizabethtown, Ky. “I would absolutely recommend proton therapy to anyone diagnosed with cancer.”

After completing treatment for prostate cancer in June, Ross returned home determined to spread the word across the state, sending a release out to Rotary clubs statewide and setting up a support group for proton therapy patients. He has three presentations on proton therapy scheduled so far.

He’s joined by Richard Sutherland, a fellow prostate cancer sufferer with whom he played golf—six rounds in seven days—and marveled at the minimal side effects they suffered while in proton therapy.

“I’ve got 15 or more friends who have had surgery or conventional radiation for prostate cancer, and I was aware of all the side effects they experienced,” Sutherland said. “Then I started reading about proton therapy. I contacted about 25 patients who had the treatment, and every one of them had the conviction that they did the right thing. During my treatment I played a lot of golf. I ate a lot of good food. And I had very few side effects.”

Richard Sutherland & Glenn Ross

Sutherland, a principal of Frankfurt-based Stantec Consulting, an engineering firm that designs transportation projects throughout the U.S.—Sutherland oversees its Kentucky projects—said he is also looking for opportunities to spread the word about Provision.

“I’d shout about it from the mountain-tops if I could,” he said. “Proton therapy is just little known among the population.”

Eleven-year-old Emma Ferrell of Winchester, Ky., found proton therapy to be a relief after enduring both regular and high dose rounds of chemotherapy for a brain tumor.

“It was pretty wonderful,” says Linda Ferrell, Emma’s mother. “Emma’s been through quite a bit over the last year. With the treatment at Provision, it was pretty easy. I’m a huge advocate for proton therapy.”

Emma and her mother were able to stay at the local Ronald McDonald house and, when Emma felt up to it, enjoyed trips to the zoo, the mall and a local herb garden.

For Lydia P., the trip Provision Center for Proton Therapy offered hope as her son Philip—after three surgeries and an unsuccessful immunotherapy treatment in Germany—continues his battle with stage 4 brain cancer.

“I prayed and said, ‘It’s got to be quick and it’s got to be covered (by insurance),” she says. “For me, it’s just the hope that he’s going to live and that he’ll have two-thirds less of his brain that’s irradiated.”

And the experience at Provision provided a place of refuge in a most difficult situation, Lydia says.

“It’s unusual that you have a group of people that care so much about the patients,” she says.

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