Proton Beam Therapy and Accountable Care: The Challenges Ahead

Elnahal, Shereef M.; Kerstiens, John; Helsper, Richard S.; Zietman, Anthony L.; Johnstone, Peter A.S.

doi:10.1016/j.ijrobp.2012.10.038

Cited by 26 publications

(8 citation statements)

References 12 publications

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“…When assessing a newer technology such as proton therapy, it would make sense to take a similar approach to develop such knowledge. However, because of the limited availability of proton therapy, patient data are limited, yet the high cost of proton therapy facilities produces pressure to fully elucidate the benefit of proton therapy [19–21]. …”

Section: Introductionmentioning

confidence: 99%

Clinical evidence of variable proton biological effectiveness in pediatric patients treated for ependymoma

Peeler

Mirković

Titt

et al. 2016

Radiotherapy and Oncology

216

230

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Background and Purpose A constant relative biological effectiveness (RBE) is used for clinical proton therapy; however, experimental evidence indicates that RBE can vary. We analyzed pediatric ependymoma patients who received proton therapy to determine if areas of normal tissue damage indicated by post-treatment image changes were associated with increased biological dose effectiveness. Material and Methods Fourteen of 34 children showed T2-FLAIR hyperintensity on post-treatment magnetic resonance (MR) images. We delineated regions of treatment-related change and calculated dose and linear energy transfer (LET) distributions with Monte Carlo. Voxel-level image change data were fit to a generalized linear model incorporating dose and LET. Cross-validation was used to determine model parameters and for receiver operating characteristic curve analysis. Tolerance dose (TD50; dose at which 50% of patients would experience toxicity) was interpolated from the model. Results Image changes showed dependence on increasing LET and dose. TD50 decreased with increasing LET, indicating an increase in biological dose effectiveness. The cross-validated area under the curve for the model was 0.91 (95% confidence interval 0.88–0.94). Conclusions Our correlation of changes on MR images after proton therapy with increased LET constitutes the first clinical evidence of variable proton biological effectiveness.

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Section: Introductionmentioning

confidence: 99%

Clinical evidence of variable proton biological effectiveness in pediatric patients treated for ependymoma

Peeler

Mirković

Titt

et al. 2016

Radiotherapy and Oncology

216

230

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“…Because of the rising costs of cancer care, there is concern that conventional PBT centers may not be sustainable in the future . Others have argued that, because the clinical and toxicity data for PBT are incomplete compared with data for photons, it will be difficult to truly assess the cost‐effectiveness of PBT .…”

mentioning

confidence: 99%

A systematic review of the cost and cost‐effectiveness studies of proton radiotherapy

Verma

Mishra

Mehta

2016

Cancer

186

145

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Group of North America for both years of existence (2014)(2015). Eighteen original investigations were analyzed. RESULTS: The costeffectiveness for prostate cancer-the single most common diagnosis currently treated with PBT-was suboptimal. PBT was the most cost-effective option for several pediatric brain tumors. PBT costs for breast cancer were increased but were favorable for appropriately selected patients with left-sided cancers at high risk of cardiac toxicity and compared with brachytherapy for accelerated partial breast irradiation. For non-small cell lung cancer (NSCLC), the greatest cost-effectiveness benefits using PBT were observed for locoregionally advanced-but not early stage-tumors. PBT offered superior cost-effectiveness in selected head/neck cancer patients at higher risk of acute mucosal toxicities. Similar cost-effectiveness was observed for PBT, enucleation, and plaque brachytherapy in patients with uveal melanoma. CONCLUSIONS: With greatly limited amounts of data, PBT offers promising cost-effectiveness for pediatric brain tumors, well-selected breast cancers, locoregionally advanced NSCLC, and high-risk head/neck cancers. Heretofore, it has not been demonstrated that PBT is cost-effective for prostate cancer or early stage NSCLC. Careful patient selection is absolutely critical to assess cost-effectiveness. Together with increasing PBT availability, clinical trial evidence, and ongoing major technological improvements, cost-effectiveness data and conclusions from this analysis could change rapidly. Cancer 2016;122:1483

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“…Identification of the factors that account for this effect may help to craft policies that optimize high value radiation treatment. This avenue of health services research is especially timely because the introduction of accountable care organizations in the United States will provide a framework for initiatives that foster responsible utilization of new technologies [31, 36–38]. …”

Section: Discussionmentioning

confidence: 99%

Intensity modulated radiotherapy for stage III non-small cell lung cancer in the United States: Predictors of use and association with toxicities

et al. 2013

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Summary Background Intensity modulated radiotherapy for stage III lung cancer has become commonplace in the United States in the absence of randomized controlled trials. We used a large, population-based database to determine which factors led to increased utilization of IMRT and to evaluate associations of IMRT with toxicities. Methods The Surveillance, Epidemiology, and End Results (SEER)-Medicare records identified 3,986 individuals aged 66 years or older diagnosed with stage III lung cancer between 2001 and 2007 and treated with IMRT or 3D conformal radiotherapy. Predictors of IMRT use were determined using logistic regression. Associations of IMRT use with diagnosis codes for radiation-related toxicities were evaluated with multivariate proportional hazards regression and propensity-score matching. Results Among the 3,986 patients studied, the median age was 75 years, 54.1% were male, and 62% had IIIA disease. Two hundred fifty seven (6.5%) patients received IMRT, with use increasing from from 0.5% in 2001 to 14.7% in 2007 (P<0.001). Key predictors of IMRT delivery included increasing year of diagnosis and treatment in a freestanding center (odds ratio, 2.10; 95% confidence interval [CI], 1.59–2.77, P<0.001); tumor size, stage, and number of radiotherapy fractions delivered were not associated with IMRT use. IMRT use was not associated with a higher burden of lung or esophagus toxicities when compared to 3DCRT. Conclusion These findings suggest that practice environment strongly influenced adoption of IMRT for lung cancer. Patient and tumor factors were not significant predictors of IMRT use. Esophagus and lung toxicity rates were similar between IMRT and 3DCRT.

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Proton Beam Therapy and Accountable Care: The Challenges Ahead

Cited by 26 publications

References 12 publications

Clinical evidence of variable proton biological effectiveness in pediatric patients treated for ependymoma

Clinical evidence of variable proton biological effectiveness in pediatric patients treated for ependymoma

A systematic review of the cost and cost‐effectiveness studies of proton radiotherapy

Intensity modulated radiotherapy for stage III non-small cell lung cancer in the United States: Predictors of use and association with toxicities

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