Advanced-Technology Radiation Therapy for Bone Sarcomas

Samir Patel, MD; Thomas F. DeLaney, MD


Cancer Control. 2008;15(1):21-37. 

In This Article

Cost of Proton Radiation Therapy

Although proton therapy clearly is capable of providing superior dose distributions compared to photon therapy, the treatment comes at a greater financial cost. Many of the current-generation, hospital-based facilities are expected to cost approximately $100 million US.[95] The issue of cost effectiveness for proton treatment is starting to be explored and is likely to receive more attention in the near future as the clinical outcomes of proton therapy trials become available. Before attempting to determine if clinical gains justify increased cost, it is important to be aware of the relative cost of proton therapy compared to the cost of photons. This is not determined easily and is likely is to change with time but has been estimated.[96]

Goitein et al[96] performed a detailed study comparing the cost for a single treatment with the most technologically advanced forms of proton and photon treatment available, IMPT and IMRT. The authors' 2003 estimate was that the cost of proton treatment was a factor of 2.4 times higher than photon treatment, but a decrease in this disparity was projected to occur with time. Capital expenditure (construction costs) and operating expenditure were considered separately. Construction costs were the dominant factor responsible for the cost difference. It was anticipated that, as more proton facilities are built,construction costs would decrease due to competition, re-engineering, and recovery of costs. A 25% decrease was expected for protons but not for photon therapy due to the fact that this technology is more mature. In terms of operating costs, a decrease was also projected for the cost for protons as more experience is gained in machine maintenance and treatment delivery becomes more efficient. Together, these improvements would bring the ratio of proton to photon cost down to 2.1. With additional improvements,the authors estimated that the cost ratio could drop to as low as 1.7. If capital expenditure were to be provided by the state or philanthropic means, this ratio could decrease even further to a ratio of 1.3 or less. There has also been interest recently in smaller,"single-room"proton treatment facilities; these may be less expensive but as these have not been built yet, the actual cost associated with these facilities remains to be determined.

Lundkvist et al[97,98] have studied the potential cost effectiveness of proton therapy in two groups of patients: pediatric patients with medulloblastoma and breast cancer patients with left-sided tumors. Though limited data are available on the long-term consequences of radiation and the cost to the healthcare system and to society, the authors concluded that proton therapy can be cost effective for select groups of patients. RT, an important component in the treatment of medulloblastoma, is associated with late adverse events in some patients. Because of the absence of exit dose, proton RT has potential to reduce the risk of adverse events compared with conventional radiation, but it is associated with a higher, initial treatment cost. The authors assessed the cost effectiveness of proton therapy compared with conventional RT in the treatment of a 5-year-old child with medulloblastoma. The patients were considered to be at risk of several types of adverse events, including hearing loss, intelligence quotient (IQ) loss, hypothyroidism, growth hormone deficiency (GHD), osteoporosis, cardiac disease, and secondary malignancies. The patients also were at risk of death and were divided into risk groups for normal death,death due to tumor recurrence,treatment-related cardiac death, treatment-related subsequent tumor death, or treatment-related other death. A review of the literature was conducted to estimate the parameters in the model. The base-case results showed that proton therapy was associated with €23,600 Euro (approximately $34,500 US at this writing) in cost savings and

0.68 additional quality-adjusted life-years per patient. The analyses showed that reductions in IQ loss and GHD contributed to the greatest part of the cost savings and were the most important parameters for cost effectiveness. The results indicated that proton RT could be cost effective and cost saving compared with conventional RT in the treatment of children with medulloblastoma if the appropriate patients are selected for the therapy. However, they also stressed that there have been few long-term follow-up studies, and more information on the long-term consequences of RT is needed.

This group of investigators also studied patients with left-sided breast cancer and documented that a decrease in cardiac death would be anticipated with proton treatment compared with conventional RT.[98] The authors were interested in evaluating whether the medical benefits of proton therapy were large enough to justify the higher treatment costs. They assessed the cost effectiveness of proton therapy in the treatment of 55-year-old women with left-sided breast cancer. Cost and quality-adjusted life years (QALYs) were the primary outcome measures. The study found a cost per QALY gained of €67,000 Euro (approximately $91,000 at this writing) for the base case analysis of an average breast cancer patient. However, the cost per QALY gained would be considerably lower if a population with high risk of developing cardiac disease was treated. The results indicate that proton therapy for breast cancer could be cost effective if appropriate risk groups were chosen as targets for the therapy.

Carbon-ion facilities are anticipated to be more costly than proton facilities. Relatively little comparative cost information is available. The proton/carbonion facility in Hyogo,Japan,which opened in April 2001, was built at a cost of 28 billion yen (approximately US $253 million), which suggests that these facilities will present significant cost issues.[95] Commercial vendors, however, are currently offering fixed carbon-ion beam facilities that are expected to be less costly.


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