A Difficult Choice

Medical breakthroughs in the treatment of cancer seldom come without a high price tag, but it's pretty hard to justify denying a particular treatment for that horrible disease by saying it's "too expensive" or that it's "too new" or that it only works for rare forms of the disease. That is just the sort of dilemma an article in today's NY Times confronts.

Medical centers are rushing to turn nuclear particle accelerators, formerly used only for exotic physics research, into the latest weapons against cancer.

Some experts say the push reflects the best and worst of the nation’s market-based health care system, which tends to pursue the latest, most expensive treatments — without much evidence of improved health — even as soaring costs add to the nation’s economic burden. [Emphasis added]

Is proton therapy simply an expensive fad? Well, apparently not. Traditional radiation therapy tends to be like the scatter shot of a shot gun shell: the x-rays used attack healthy tissue surrounding the tumor as well as the tumor itself. Proton therapy, on the other hand, is far more precise and most of the beam can be guided to the tumor itself. So what's the problem? Well, first of all there's the expense. Building a center to house one of the devices and the device itself tends to cost in the $100 million range. That's just the initial investment. To cover that kind of expense, the therapy has to be used and used a lot. Then there's the efficacy of the treatment.

Once hospitals have made such a huge investment, experts like Dr. Zietman say, doctors will be under pressure to guide patients toward proton therapy when a less costly alternative might suffice. ...

Dr. Zietman said that while protons were vital in treating certain rare tumors, they were little better than the latest X-ray technology in dealing with prostate cancer, the common disease that many proton centers are counting on for business.

“You can scarcely tell the difference between them except in price,” he said. Medicare pays about $50,000 to treat prostate cancer with protons, almost twice as much as with X-rays. ...

An economic analysis by researchers at Fox Chase Cancer Center in Philadelphia found that proton treatment would be cost-effective for only a small subset of prostate cancer patients. [Emphasis added]

And that's the dilemma. The new therapy is much more effective than traditional radiation therapy for spinal, head, and child tumors, but those are rare. Does the cost-effective analysis then mean we shouldn't have the new technology? That hardly seems fair to those who would get the benefit of the treatment.

Unfortunately, like new prescription medicines that are only marginally an improvement over the last generation's offering, doctor's too often feel compelled to use the latest formulation, especially if their patients are demanding it.

Limiting the number of such centers might be the answer. For example, Southern California has such a center at Loma Linda. Does it also need one at Hungtington Memorial, County-USC, and Cedars-Sinai? If the treatment is limited to just those tumors it works on, will there still be waiting lists?

I'm not sure. Like I suggested, it's a dilemma, a difficult choice.