Current practice in proton therapy delivery in adult cancer patients across Europe

Abstract

Background and purpose: Major differences exist among proton therapy (PT) centres regarding PT delivery in adult cancer patient. To obtain insight into current practice in Europe, we performed a survey among European PT centres. Materials and methods: We designed electronic questionnaires for eight tumour sites, focusing on four main topics: 1) indications and patient selection methods; 2) reimbursement; 3) on-going or planned studies, 4) annual number of patients treated with PT. Results: Of 22 centres, 19 (86%) responded. In total, 4233 adult patients are currently treated across Europe annually, of which 46% consists of patients with central nervous system tumours (CNS), 15% head and neck cancer (HNC), 15% prostate, 9% breast, 5% lung, 5% gastrointestinal, 4% lymphoma, 0.3% gynaecological cancers. CNS are treated in all participating centres (n = 19) using PT, HNC in 16 centres, lymphoma in 10 centres, gastrointestinal in 10 centres, breast in 7 centres, prostate in 6 centres, lung in 6 centres, and gynaecological cancers in 3 centres. Reimbursement is provided by national health care systems for the majority of commonly treated tumour sites. Approximately 74% of centres enrol patients for prospective data registration programs. Phase II-III trials are less frequent, due to reimbursement and funding problems. Reasons for not treating certain tumour types with PT are lack of evidence (30%), reimbursement issues (29%) and/or technical limitations (20%). Conclusion: Across European PT centres, CNS tumours and HNC are the most frequently treated tumour types. Most centres use indication protocols. Lack of evidence for PT and reimbursement issues are the most reported reasons for not treating specific tumour types with PT.

Clinical use and future requirements of relative biological effectiveness: Survey among all European proton therapy centres

“…The tumour entities treated by most participating centres are brain and head and neck tumours, which is in line with a study on the current practice in proton therapy delivery in Europe [35]. In brain tumour patients, radiosensitive OAR are usually situated close to the target volume, resulting in areas being exposed to high dose and high LET and, therefore, at risk of more pronounced clinical effects due to an elevated RBE dose.…”

Inequality in Accessibility of Proton Therapy for Cancers and Its Economic Determinants: A Cross-Sectional Study

“…Although the number of PT centers increased rapidly, their average volume was relatively stable. According to surveys of European PT centers, in 2020, the average number of patients treated by a PT center is 223 (range of 29–950) ( 25 , 26 ), which is similar to that in 2015 (221, range of 40–557) ( 26 ). Thus, increasing the number of PT centers played an important role in getting more patients treated by PT.…”

“…( 25 , 26 ) In this study, we found the extremely high inequality in accessibility of PT centers among all countries in the world (Gini = 0.96), which is even more severe than the inequality observed in economic development (Gini = 0.87 for GDP). Our empirical data analyses showed that the total GDP had a significant impact on whether a country had a practical PT center, whereas the total GDP and GDP per capita had significant impacts on the number of PT centers.…”

“…It is worth noting that, despite of a significant initial investment is required for PT, construction of a PT center is only the first step of getting patients access to PT. According to a recent survey among 19 PT centers in Europe, the top reasons why patients with cancer not receiving PT were lack of evidence for the effectiveness of protons over photons, reimbursement issues, technical issues, and patient referral ( 25 ). Although PT is not new, the high costs of setting up and operating PT facilities limited the research and development, which is needed to maximize its clinical efficacy ( 29 ).…”

“…Although PT is not new, the high costs of setting up and operating PT facilities limited the research and development, which is needed to maximize its clinical efficacy ( 29 ). Because of lack of funding and reimbursement and methodological issues in conducting randomized controlled trials (RCTs), evidence from phase II or phase III clinical trials was limited ( 25 ). More RCTs or real-world studies are needed to generate high-quality level 1 evidence ( 30 ).…”