ASTRO'S New Model Policy Supports Proton Therapy for Pediatrics

The American Society for Radiation Oncology (ASTRO) has issued a new Model Policy for proton beam therapy (PBT) that details which cancer diagnoses meets ASTRO's evidence-based standards and should be covered by private insurers and Medicare.  Developed by leading radiation oncologists and medical physicists, including significant input from expert representatives in proton therapy, this Model Policy supports PBT coverage for appropriate patients and identifies areas where coverage with evidence development and further research are needed.  

PBT's reduced radiation dose to healthy tissues is attractive because it can reduce side effects for patients, which potentially increases their quality of life. To date, scientific evidence exists confirming that PBT is particularly useful in a number of pediatric cancers, particularly those in the brain, as well as for certain adult cancers such as ocular melanoma.

In identifying and describing appropriate use of proton-beam therapy, the policy lists four circumstances when use of the technology is reasonable (and most pediatric cases would then qualify):

1.      Target volume is close to a critical structure, requiring a steep dose gradient outside the target to limit the structure's exposure.

2.      A decrease in dose inhomogeneity in a large treatment volume is required to avoid an excessive "hotspot" within the target volume.

3.      Use of photon-based therapy carries an increased risk of clinically meaningful normal-tissue toxicity.

4.      The same area or an adjacent area has been previously irradiated, increasing the need for sculpting to limit the cumulative radiation dose.

 

Proton therapy is a cost-effective treatment for pediatric brain tumor patients

Atlanta, September 22, 2013

Due to decreased side effects, it may also be cost-saving

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PDF of press release and abstract

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Proton therapy, an external beam radiotherapy in which protons deliver precise radiation doses to a tumor and spare healthy organs and tissues, is cost-effective in treating medulloblastomas, fast-growing brain tumors that mainly affect children, when compared to standard photon radiation therapy, according to research presented today at the American Society for Radiation Oncology’s (ASTRO’s) 55th Annual Meeting.

The study used a first-order Monte Carlo simulation model to examine a population of 18-year old survivors of medulloblastoma brain tumors who were assumed to have been diagnosed at age 5 and at risk of developing 10 adverse health events, including various hormone deficiencies, coronary artery disease, congestive heart failure, ototoxicity, secondary malignant neoplasm and death. Primary institutional information on the cost of investment and Medicare data regarding the cost of management of the various adverse health conditions, in addition to peer-reviewed publications analyzing incidence of side effects were used in the simulation model to perform a cost-effectiveness analysis comparing proton and photon therapy from the societal perspective. Outcomes were measured in incremental cost-effectiveness ratios, with costs measured in 2012 U.S. dollars (USD), and effectiveness measured in quality-adjusted life years (QALYs). A societal willingness-to-pay (WTP) threshold of $50,000/QALY was the benchmark.

The clinical benefits of proton therapy have been recognized in reducing side effects when compared to photon therapy, but the significant expense of building and maintaining proton facilities and the high treatment costs have been areas of concern. The study’s results demonstrate that by avoiding years of costly side effects, proton therapy can be cost-effective for children with medulloblastoma. Using current risk estimates and data on required capital investments, proton therapy for pediatric medulloblastoma treatment was not only cost-effective compared to standard photon radiation, but also found to be cost-saving in many simulations.

Results from the base case analysis showed that due to the prevention of side effects, proton therapy was cost-saving. In sensitivity analyses, proton therapy strongly remained the more appealing treatment, in part due to decreased risks of hearing loss, secondary malignancy and heart failure, resulting in cost-savings in more than 95 percent of simulations.

“We believed that proton therapy might prove to be cost-effective in treating pediatric brain tumors, and we were intrigued that it also proved to be cost-saving in the base case and in almost all of the sensitivity analysis simulations,” said Raymond Mailhot Vega, MD, MPH, the presenting author of the study; a resident at Mount Auburn Hospital, the teaching hospital of Harvard Medical School; and a 2014 radiation oncology resident at New York University’s Langone Medical Center. “Proton therapy might prove to be both cost-effective and cost-saving for other malignancies, too, and consequently, more cancer patients may benefit from proton therapy.”

The abstract, “Cost-Effectiveness of Proton Therapy Compared to Photon Therapy in the Management of Pediatric Medulloblastoma,” will be presented in detail during a scientific session at ASTRO’s 55th Annual Meeting at 1:45 p.m. Eastern time on Sunday, September 23, 2013. To speak with Dr. MailhotVega, please call Michelle Kirkwood on September 22-25, 2013, in the ASTRO Press Office at the Georgia World Congress Center at 404-222-5303 or 404-222-5304, or email Michelle Kirkwood.

ASTRO’s 55th Annual Meeting, held in Atlanta, September 22-25, 2013, is the premier scientific meeting in radiation oncology and brings together more than 11,000 attendees including oncologists from all disciplines, medical physicists, dosimetrists, radiation therapists, radiation oncology nurses and nurse practitioners, biologists, physician assistants, practice administrators, industry representatives and other health care professionals from around the world. The theme of the 2013 meeting is “Patients: Hope • Guide • Heal” and will focus on patient-centered care and the importance of the physician’s role in improving patient-reported outcomes and the quality and safety of patient care. The four-day scientific meeting includes presentation of four plenary papers, 363 oral presentations, 1,460 posters and 144 digital posters in 70 educational sessions and scientific panels for 19 disease sites/tracks. Keynote speakers include: William B. Munier, MD, Director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality; Darrell G. Kirch, MD, President and CEO of the Association of American Medical Colleges; James Cosgrove, PhD, Director, the U.S. Government Accountability Office; Otis W. Brawley, MD, Chief Medical Officer of the American Cancer Society; and Peter Friedl, MD, PhD, of St. Radboud University Nijmegen Medical Centre at the University of Nijmegen and MD Anderson Cancer Center.

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Pediatric Proton Foundation Objects to 55% Reduction in OPPS Payment Rates for Level II Proton Beam Radiation Therapy

In keeping with its mission of providing advocacy for pediatric cancer patients seeking proton therapy, the foundation filed a written comment letter to the Department of Health and Human Services regarding serious concerns about the planned reduction in OPPS payment rates for Level II Proton Beam Radiation Therapy. PPF went on to explain that..." 75% of young patients treated with proton therapy had brain tumors. More than half of those children treated were under nine years old. To reduce the proton center's ability to recover their cost when treating children, the most vulnerable population who is least able to articulate their concerns, will mean that less valuable treatment slots are being used for our children."

2011 Pediatric Proton Survey Results Announced

National Association for Proton Therapy and Pediatric Proton Foundation 2011 Survey Reveals 32% Increase in Pediatric Cases Treated at U.S. Proton Centers

Brain cancer continues to be the main tumor target for proton therapy - an advanced form of radiation treatment according to the National Association for Proton Therapy and the Pediatric Proton Foundation.

Click here for 2011 Pediatric Proton Survey Results

Treating Brain Tumors in Children

FROM THE HEALTH GUIDE:

Of all the different kinds of solid tumors that a child might get, the brain tumor is the most common one. What causes brain tumors in children?

As with any other kind of tumor, a brain tumor comes about when a cell somehow gets out of control and multiplies uncontrollably. For the most part, science doesn’t yet have an answer to what causes brain tumors in children exactly. But scientists do suspect genetic reasons and environmental influences.

When a pediatrician suspects a brain tumor in a child, the first thing he does is to order an MRI or CT scan. A child needs be very still for any one of these scanning devices to work properly. Most of the time, with very young children, the doctor sedates the child so that she’ll stay still enough. Sometimes, if the results of the scan don’t seem conclusive enough enough, they’ll even try to do a biopsy – where they actually take out material from the brain.

It can take a whole team of specialists to successfully treat brain tumors in children. Most of the time, a child who is affected in this way will need surgery, chemotherapy and even radiation therapy. Treatment techniques have improved considerably now. Most of the time, the child will come out in one piece.

But it can be a very complicated process treating brain tumors in children. Typically, the team of doctors treating the child will include a neurosurgeon, a neurologist, a pediatric radiation therapist, a neuro-oncologist who specializes in children and so on.

Medical science is now clear about how brain tumors in children should be treated – it should be treated aggressively. And so, pediatric neurosurgeons are usually able to produce better outcomes – now that they know what exactly they need to do. The fact that there is all this high-tech equipment that they have at their disposal, helps too.

These days, they usually conduct pediatric brain tumor surgery in stages. They don’t go in and remove the tumor all at once. They do it a little bit at a time, over several operations. When they do it this way, they are able to make use of intervening periods to apply radiation therapy to the tumor so that it will shrink. The doctors hope that when they do this, they can be as non-invasive is possible. The third new techniques coming online all the time.

Instead of using radiation traditional radiation, the doctors use something called proton beam therapy.

In the future, all brain tumors in children will be treated this way. Proton beam radiation is a far more precise a way of going about it. There is no collateral damage to tissue that’s close to the tumor.

www.thehealthguide.org/tumors/treating-brain-tumors-in-children/

Neuropsychological Testing and Pediatric Proton Therapy

I am a lucky person in serving in my role as the Executive Director of the Pediatric Proton Foundation because I get to interact with health care professionals and convey to you what’s on their minds.  Recently, I visited Philadelphia and Indiana and sat with the Neuropsychological teams at both centers.  Here is what I learned that you need to know:

1.  If your child has been diagnosed with cancer and is well enough, you should get a complete neuropsychological test to establish a baseline as soon as possible.  Neuropsychological testing involves giving a child a number of tests that provide information about how the brain works in the areas of memory, speed, language, visual processing, auditory processing, integration of information, emotional and behavioral regulation, and planning and organization.  The tests are age appropriate. These tests are administered by a trained professional usually a licensed psychologist and should be done by your doctor, not your school.

2.  The typical neuropsychological problems exhibited by childhood-cancer survivors involve processing speed, memory, working memory, organizational skills, time management skills, math skills, and social skills. These deficits have clear implications for success in the educational environment.

3.  All cancer treatments including chemotherapy and proton therapy can cause late effects to include cognitive deficits.  This is still a very new area in terms of understanding what specific chemo drugs cause problems because most chemo protocols are a mixture of various drugs.  However, it is well-documented regarding the late effects of radiation to the brain and spinal cord and other organs.

4.  Knowing the late effects will not probably not change the protocol that you need to follow for your child; however, testing helps establish what effects may be associated with cancer treatment as compared to other normal causes.

5.  Many late effects take years to really show in academics because earlier studies are easier to process as compared to more difficult tasks later in middle school and high school.

6.  Recommendations from the neuropsychological examination may include specific professional interventions that can be incorporated into a child’s Individualized Education Program (IEP).

7.  All the professionals I met with recommended annual testing.  Many insurers will only pay for it every three years.  Read your healthcare handbook and know your rights.

Pediatric Proton Responds to New York Times Opinionator Article

There was an article published in the New York Times yesterday.  You can read it here:

http://opinionator.blogs.nytimes.com/2012/01/02/it-costs-more-but-is-it-worth-more/

The Pediatric Proton Foundation responded as follows:

As the mother of a child that survived paralyzing spinal cancer at the age of 2 in part due to proton therapy, I feel compelled to respond to this article. As you indicate in your article, there is mounting evidence that protons will become the standard of care for cancer treatment for pediatric patients, especially when it comes to brain and spinal tumors. The problem for most parents is accessing proton therapy for their cancer-stricken child. With only 9 centers in the U.S., it often involves a temporary move for the family during the proton treatment which is often cost prohibitive (we traveled over 1,500 miles.)  Sadly, only 465 children received proton therapy in the U.S. in 2010, and as you indicate over 3,500 could have benefited. To solve this problem, we need to have more access for our children through more proton centers. I congratulate Mayo for making this important investment on behalf of all pediatric cancer patients, and I thank you on behalf of my son, now age 6, NED and healthy.

Pediatric Proton Foundation to Hold Annual Meeting at ASTRO

The Annual Meeting of the Pediatric Proton Foundation will be held at ASTRO in South Miami Beach the first week of October.  Wow!  As we look back on the year, we have so many accomplishments to be proud of given our limited size.  For the first time we published a survey in conjunction with the National Association for Proton Therapy entitled, "Pediatric Proton Therapy in the United States: Patterns of Care 2010."  We were impressed with the findings which revealed 45 diseases were treated in 2010.  Children under 8 being the majority of those pediatrics treated.  We will be reporting these and other findings during our meetings and fellowship during ASTRO.  Stay tuned!

 Thank you for your continued interest in pediatric proton. 

Pro Proton!

When I was writing the press release announcing the pediatric proton foundation, one thing I tried to explain was the finding out about proton treatment gave us hope at a time that we desperately needed it. I don’t know how to describe finding out my son had cancer. At first, I was in denial though I knew the doctors didn’t have time to wait for me to get to acceptance. Everything from the moment we heard tumor went like lightening. You see my son was paralyzed. There was cancer and there was a tumor pressing on his spinal cord. We agreed to do emergency surgery. In this time and shortly after my son’s initial diagnosis, my father-in-law suggested we look at proton. He called Boston and Jacksonville and both places supported Jacob being considered as a patient. I believe my father-in-law being a chemical engineer understood the terrible toxicity of chemo drugs and the harm it would do to my son’s young body. We heard from the doctor’s themselves that there are no new chemo drugs and the ones that would be used on Jacob were 30 to 40 years old. They cause temporary and permanent damage to the healthy tissues along with the cancer tissue. The only changes that have been made to protocols are how much gets used in what combination and how often. That’s it.

I remember being angry that this was all the choice we had. I began searching online every waking hour in regards to ewing’s sarcoma, the drugs Jacob would be on, the protocol, the clinical trials. Many hours and hours. Slowly, I began to include proton treatment in my research once I understood radiation is part of the cure. My sister-in-law, a nurse, also supplied us with information on proton. Suddenly, I thought my son CAN beat this thing. Doom and gloom turned to hope. He had to be given the best chance of killing the cancer and still leading a normal life. We knew the chemo was bad, but did the radiation phase have to be archaic too? Did we have to watch our son’s back be zapped by 40 year old radiation machines and destroy his little infrastructure? NO, we didn’t.

We fought hard and worked day and night and got our son accepted to MD Anderson’s proton therapy center. This is why we are here today as the Pediatric Proton Foundation. We believe every child deserves to have proton as their radiation therapy when fighting cancer. These children fighting cancer already have the cards stacked against them in so many ways. I understand why proton is often called the “beam of hope”. When life seems bleak and your child faces a possible death sentence, proton is just the bright spot of hope you need, for survival of cancer and survival of the late effects of the treatment itself.

We are “Pro Proton!”

New Centers in 2009

Soon we will have 7 proton centers operating in the U.S.! The more the merrier if you ask me.

Procure's Oklahoma City Proton Center will open July 8, 2009 and is already accepting inquiries and beginning to schedule patients for consultations. This center can be reached by calling 888-847-2640. Some pediatric patients may be able to be treated there depending on if they need anesthesia. You can check out this new center by going to http://www.procure.com/. They have a nice newly designed website with tons of information available.

The other new center will be opening in November 2009 in Philadelphia - the Roberts Proton Therapy Center. This center can be reached by calling 1-800-789-PENN(7366). You can visit this center on the web at http://www.pennhealth.com/. They are planning to have a gantry room dedicated to pediatrics so this makes me very happy.

I was reading some of the very latest information available on protons versus photons, and it is indisputable regarding the superiority of protons in use for children. Children are still developing and having radiation hit healthy tissue can cause devastating effects. Especially when a child has a brain tumor. The brain is very sensitive to radiation. Doses as low as 18 gy can cause developmental delays, hearing problems, loss of iq (this happens every year after radiation for many years to come) and many other terrible problems. I heard a very reknowned radiation oncologist for St. Judes discuss this subject and it made me get goose bumps hearing the devasting effects of radiation to the brain. He touted the scientific evidence as showing protons vastly superior over photons or IMRT especially with brain tumors. I asked him why doesn't St. Judes have proton then? He said I would have to ask the powers that be. I plan too. Many parents flock to St. Judes because they are the only pediatric hospital dedicated to solely to pediatric cancer. Of course, I understand children can be referred to the other centers, but still.

I may be like a caped crusader here. Just an empowered Mom that feels her son's life was saved with protons. I am making it my job to make these facts known. I hope someday to get the attention of the media. My goal is to make sure in my lifetime that all of our cancer kids that need radiation treatment can get to the protons. Having more centers will ensure more slots are available for the children that truly have the most to gain from proton treatment. Join me in this effort - will you? Check out our website: www.pediatricprotonfoundation.org.