T

axpayers in Louisiana are helping to subsidize construction of two health care centers offering a divisive cancer treatment — even as state lawmakers prepare to cut millions from basic health services.

The treatment is called proton therapy, and this spring, the state’s economic development department promised up to $10.6 million to two companies, one to build a center in Baton Rouge and the other in New Orleans.

Proton therapy is touted as a procedure with low side effects — a pencil-sized beam of protons is shot directly at tumors, with the goal of sparing the healthy tissue around it. It’s a therapy that only works well on a few cancers, and hasn’t had rigorous trials to test its more global efficacy. It’s a big gamble with tax dollars in a state where the Legislature is trying to pare more than $200 million from its health care budget.

advertisement

“Changing technologies are a risk,” said Louisiana Economic Development Secretary Don Pierson. “For proton therapy, we don’t know five years from now if there will be a neutron beam, or something, that changes how they treat cancer.”

Health care companies often work with governments to build facilities, typically through bonds or subsidies, or through university partnerships that could potentially absorb more risk. But, with a medical community divided on whether this more expensive treatment is better than traditional radiation therapies, it brings to question why economic development agencies, whose bread and butter is job creation and tax base development, would roll the dice on these investments.

Pierson said he believes proton therapy could help turn Louisiana into a lucrative medical tourism hub. State officials, including the governor, are sold on the idea of a live-saving procedure, even if only a few people will benefit.

That reasoning doesn’t sit well with some experts, including Amitabh Chandra, director of health policy research at Harvard’s Kennedy School of Government. State funding, Chandra said, should value health outcomes instead of economic ones.

“The purpose of a proton center is to cure cancer — not to be a job program,” said Chandra. “I’ve compared it to the Death Star — nothing so big and so useless has ever been discovered in medicine. It’s hard to believe we should be paying handsomely for technology whose benefit is unproven.”

Newsletters

Sign up for our hospitals newsletter, On Call

Please enter a valid email address.

‘Victory bells’ but little evidence

The proton therapy center planned for New Orleans might someday resemble a smaller version of what’s going on Knoxville, Tenn., where Provision operates one of the nation’s newest proton treatment facilities.

Every year 900 patients flock to this $119 million facility for what’s pegged as minimally invasive cancer care. Inside three pristine treatment rooms, patients lay motionless as a giant particle accelerator weighing nearly as much as the Statue of Liberty throws a thin beam made of protons directly at cancerous tissues.

 

Proton Therapy Tenn.
To reduce costs, Provision Healthcare makes its proton therapy systems in-house. Max Blau/STAT

Provision CEO and Chairman Terry Douglass said 70 percent of patients in Knoxville are self-referrals — some traveling from as far as China or Russia. The treatment is likened to a vacation — Provision has rolled out a brochure-filled concierge desk for patients to plan outings, and the facility is designed to feel homey with fireplaces in the lobby and outdoor picnic tables located near a small waterfall.

Provision celebrates treatment “success” publicly: People gather in the lobby whenever a patient rings the “victory bell” following his or her final treatment; each is given a lapel pin to become proton therapy “ambassadors.”

But proton therapy has a high price tag: treatment runs between $30,000 and $120,000, according to MedPage. More common radiation therapies cost between $12,000 and $15,000, and tend to be covered by insurance.

And the scope of treatment is limited — experts generally agree proton therapy is the best for children with brain tumors, for example. But, the consensus ends there: experts say evidence hasn’t shown proton therapy to be better than conventional treatments for treating common cancers.

The net result: there are 24 proton centers in the U.S. They have the combined capacity to treat more than 21,000 people per year. Only 7,000 people were treated at those centers, according to a survey by the National Association for Proton Therapy.

“The reality is this is an expensive treatment,” said Dr. J. Leonard Lichtenfeld, deputy chief medical officer for the American Cancer Society. “More expensive doesn’t make it a bad treatment, [but] highly competent radiation oncologists disagree whether the data is sufficient or not.”

Centers close, partnerships break

Even as Provision continues to expand — proposals for facilities near Orlando, Fla., and Nashville, as well as New Orleans, plus eyeing development for a dozen more — not everyone is convinced.

Dr. Tomasz Beer remains wary about the treatment. Five years ago, the deputy director of Oregon Health and Science University’s Knight Cancer Institute said his colleagues considered investing millions into proton therapy. Ultimately, they felt the Portland area, home to 2.3 million people, had too few appropriate patients. Strong results from a clinical trial would have made a difference, he said.

“Treatment should start with what’s best for patients,” Beer said. “We get into trouble when we don’t do that thinking with technology that’s out of proportion to the clinical need.”

Three years ago, the Indiana University Proton Therapy Center shuttered after a decade in business due to a “dwindling patient base.” Earlier this year, owners of San Diego’s Scripps Proton Therapy Center filed for bankruptcy after the $220 million site had struggled to break even. Even the university partnership proposed for the Knoxville center four years ago fell apart.

Many centers bank on high volumes of prostate cancer patients to make money, even though some oncologists dispute its effectiveness. To offset financial risk, developers have pivoted toward smaller facilities with fewer treatment rooms. Provision has even gotten into the business of building its own proton therapy systems to drive down costs.

Therapy centers in Alabama, Michigan, and Washington, D.C., have listed their projects’ price tags at under $50 million. Provision’s New Orleans project is expected to cost $100 million.

“We’re not trying to build a $250 million cancer center,” said Steve Hicks, chairman and CEO of Provident Resources Group, the nonprofit behind the Baton Rouge proton center, which he said would cost $85 million. “We’re simply trying to meet demands of the market.”

 

Proton Therapy Tenn.
Patients wear custom molds to ensure they stay motionless as they receive proton therapy. Max Blau/STAT

A health care economy that needs help

Where lawmakers and hospital officials might balk because of patient-centered concerns, economic development agencies see proton therapy as an income driver — Louisiana joins Texas in using economic development funds to expand proton therapy in the state.

Pierson, the Louisiana economic development official, said the agreement brings 155 high-paying jobs to a state whose health care economy was decimated after Hurricane Katrina in 2005. Louisiana doesn’t give away the dollars up front, but as soon as these providers treat their first patients, they stand to receive public dollars for as long as a decade. But Greg Sonnenfeld, director of Shreveport’s Willis-Knighton Cancer Center, the only proton therapy provider currently in Louisiana, said recruiting and retaining specialists well-versed in the technology has been a struggle.

Alongside a flagging health care economy are some of the poorest health care outcomes in the nations. Gov. John Bel Edwards has said he’ll veto the million-dollar cuts that could ax everything from Zika virus prevention to mental health services for low-income residents.

However, some cuts may be inevitable, Chandra said, so funding an experimental cancer treatment while trying to cut preventive care seems misguided. He calls the decision to bankroll unproven therapies like proton therapy “unfortunate.”

“We don’t know if the treatment is better — or if it’s cost-effective,” he said. “For governments propping these centers open, it’s not aligned with moving health care toward value at all.”

This story has been updated with details about the Louisiana agreement.

Leave a Comment

Please enter your name.
Please enter a comment.

  • Seems like a misfire to take aim at a company that’s trying to fix the problem you’re complaining about- high cost. If it wasn’t for innovators like Provision, many treatments commonly utilized today would still be too expensive. In the meantime, a couple dozen proton centers that do exist provide treatments to patients who will be better off with proton therapy, often times for free. This is a heavily studied and endorsed treatment for multiple indications. In many cases, the cost is actually lower than the alternative due to reference pricing and reduced side effects. Why do you oppose innovation that will expand access to this treatment? Not everyone needs proton therapy but enough people in Louisiana, a state with high cancer mortality, need it to justify the new development. The top cancer centers in the country utilize proton therapy. The NHS, who deserves admiration, is developing multiple proton therapy centers in the U.K. and for years has paid for patients to fly and stay across the world to receive proton therapy in the United States. There are many causes for overspending in healthcare and cancer care. You picked a speck, proton therapy, to make an example of – and a company, Provision, who is innovating to reduce the cost. Misfire.

  • I just completed a Proton therapy radiation treatment at MGH. In my case, I had a cancerous tumor in my face. Any radiation treatment is difficult for the patient. As this treatment was. But, it seems to have done what the doctors who recommended it intended. The tumor has been reduced to nothing. I am a bit surprised to read that it is not considered a “proven” course of treatment for certain types of cancer.

  • Several core principles of journalism have been violated in this article- truth and accuracy, fairness and impartiality, and humanity.

    “Experts say evidence hasn’t shown proton therapy to be better than conventional treatments for treating common cancers.” Which experts? A urologist who probably performs prostatectomies on dozens of patients each year, knowing their biopsy showed high-risk for recurrence, and they will likely be told they need radiotherapy in their post-op follow-up anyway? Did you ask a health insurance CEO who makes an $11 million annual salary, taking the corporate jet on vacation? A conventional radiation oncologist who doesn’t have access to proton therapy? Is an economist an expert in medical physics and radiation oncology? There is a reason Provision wants their patients to become ambassadors after treatment- they are the ultimate experts. Their treatment experience, and how they go on to live a better quality of life after treatment, is truth.

    You say there is no evidence. The “evidence” may be limited due to the challenge of conducting randomized trials comparing proton therapy to conventional radiotherapy, but there is some evidence and proton centers are working to collect more where possible. Furthermore, comparative plans show outstanding differences in dose to organs at risk, favoring proton therapy.
    The purpose of proton therapy IS to cure cancer; positive economic impact is just a fringe benefit because proton therapy is not widely available; an advantage that will fade as proton therapy becomes less of a novelty and more of a standard of care. You completely fail to mention that two of the three top cancer centers in the US offer proton therapy.

    In 2016, there were roughly 40 cases of Zika virus in Louisiana, but the state has one of the highest cancer mortality rates in the US with approximately 160 cancer deaths per week! And you suggest the state shouldn’t invest in this cancer treatment? Proton therapy benefits the local community in terms of both clinical and financial outcomes.

    Hospital care and physician services only account for half of healthcare spending. Why wouldn’t you focus on the real parasites- the Health Insurance Industry?! They are the reason for the “dwindling patient base”, despite the fact that Medicare covers most indications for proton therapy. Why make an effort to defame a small cancer center that is battling the insurance industry for coverage, offering charity care to more patients than most healthcare institutions, and even working to reduce the cost of proton therapy??

    One of the fundamental lessons I learned in school was to always treat my patient as if he or she were one of my own loved ones. Mr. Blau, if your loved one had breast cancer, would you want her to have conventional radiation that can damage her heart or lungs, only for her to go on to have a secondary cancer or heart attack? Or would you prefer she have proton therapy because WE KNOW these vital organs will not receive unnecessary radiation dose. You point out that the facility in Knoxville is “designed to feel homey with fireplaces in the lobby”. Are you suggesting cancer patients should have to go to a stark, depressing facility for their treatment every day?

    This is a shortsighted story for those who are focused on progressive cancer care, and most importantly to those who are in the fight against cancer.

    • You might be interested in Dr. Elisabeth Rosenthal’s recent book “An American Sickness,” in which she discusses the economics of proton therapy.

  • Can’t be that effective with largely mixed results. Just more crony capitalism. Take tax dollars of people with little and transfer it to rich business people who administer (dubious and expensive) healthcare to the only people who can afford it: other rich people.

    Another transfer of public coffers from poor to rich. The new American business plan.

Sign up for our Morning Rounds newsletter

Your daily dose of news in health and medicine.

X