Comment on: Insurance coverage decisions for pediatric proton therapy

Abstract

Kayser address the important issue of insurance approval for pediatric cancer therapy. As clinicians, we all feel the strain from arduous insurance approval processes that take time and resources away from patient care.What was most surprising about the paper was the near-universal insurance approval for proton beam therapy (PBT) even though it has not yet been convincingly shown to be superior to intensity-modulated radiotherapy (IMRT). The theoretical benefits of achieving higher conformity and sparing healthy tissue are well established. Ojerholm and Hill-Kayser demonstrate that insurance will cover PBT, but does that mean that we should refer? There is evidence that PBT is superior to IMRT and even cost effective in a limited number of clinical scenarios, although the cost-benefit analysis is based on similarly limited data. 6,7 However, the diagnoses described in the paper are much broader including a variety of solid tumors.Proton beam centers are geographically scattered leaving patients to travel long distances for a technology that costs several times as much as IMRT before the cost the family bears for travel, lodging, and food during treatment. The cost of a PBT center ranges from $25 to $250 million. 8 A new PBT center with $100 million of funded debt has to generate $800,000/month to just pay the principle and interest on the debt, which does not include expensive fixed costs like staffing and utilities. 8 These economic pressures create a strong incentive to push the modality based on theoretical benefits before the outcomes data matures. Despite insurance coverage, families are responsible for an ever increasing portion of their bill. We know that medical debt is a leading contributor toward bankruptcy in the United States, 9 and many families of patients with pediatric cancer will develop food, housing, or energy insecurity because of treatment costs. 10 The willingness of insurance companies to approve PBT based on limited evidence puts the onus on clinicians to make careful referrals and push for RCTs. Ojerholm and Hill-Kayser showed that the patient base exists to design appropriately powered RCTs. Pediatric oncology provides many examples of the power of multicentered RCTs to improve outcomes. The best way to ensure insurance coverage is to definitively show that PBT is worth the cost and benefits patients.

Reply to comment on: Insurance coverage decisions for pediatric proton therapy

“…To the Editor: Dr. Schefft raises several important points. 1 First, proton beam therapy (PBT) has potential benefits, but level 1 evidence to support its use does not exist. Second, the cost of these expensive treatments is partially shouldered by patients and families.…”