The proton therapy center at Penn Medicine.
While there are currently only 22 proton therapy centers in the United States, the growing interest in the advanced cancer therapy is causing more hospitals to weigh the benefits against the high cost of opening their own centers.
Luckily, while centers once cost between $120 and $200 million, new refinements in the existing technology are lowering costs at a time when more cancer patients are looking for this treatment option.
A conventional X-ray beam used in radiation therapy goes in one side of the body and comes out the other, doing damage to not just cancerous tissue but the healthy cells that surround it; proton beams, by contrast, can be stopped at a fixed point, and molded to the dimensions of the affected area. So not only is the healthy surrounding tissue largely unaffected, but tumors that were previously inoperable are now treatable. That includes tumors next to vital organs, or even at the base of one's spine.
Penn Medicine has had a proton therapy center since 2010. Its chair of radiation oncology, James Metz, said more hospitals and systems are considering the inclusion of proton therapy in its treatment options, largely because establishing the technology is no longer as cost prohibitive as it once was.
"The cost has come down substantially from what it was a decade ago," said Metz. "It used to be at least $100 million for an entry point. Now it's $30, $40 million. A lot of players didn't have the financial ability to get into the game at the time."
The more recent focus, he said, has been on smaller facilities with smaller footprints, which has reduced the amount of up-front cost.
That's not to say there isn't a financial risk. Metz said many centers that built proton-only facilities are struggling. Better, he said, to offer it as part of a larger overall treatment package.
"I see proton therapy as a tool in the toolbox," he said. "When it's built with traditional radiology equipment, if offers you a range of services you wouldn't have with just radiation therapy alone."
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While proton technology has been around since the 1940s, the first center in the United States wasn't built until around 1960, and it's only been during the past 10 to 15 years -- when MRIs and CT scanners became more prevalent -- that more institutions were able to take advantage of the targeting ability of protons. An increasing number of centers have come online since that time.
If the technology continues to evolve, it may catch on even more.
The team at Mevion Medical Systems is attempting to make proton therapy less cost prohibitive for cancer treatment facilities, and it's been doing it largely by shrinking the accelerator technology needed to produce the protons themselves; in that way, it's following the model of smartphones, which shrunk computing power into something more affordable, portable and pocketable.
"When people first started using protons … the treatment was effective, but the treatment centers were very, very expensive," said Mevion CEO Joe Jachinowski. "They were the size of a football field, and they cost a lot of money because they required lots of staff and high amounts of energy. It was a good therapeutic approach, but very much hampered by the complexity."
The newest proton accelerators, he said, are now of a similar size and nature to a conventional X-ray machine, such that a hospital can add a single-room proton center to their existing treatment facility. The cost? A little less than $30 million.
"Historically, proton centers were barely economically viable," said Jachinowski. "They had very long payback periods. There actually have been several around the country that have had significant enough financial issues that they basically changed hands at a significant discount to their original construction price, because the patient volumes never showed up to fill those treatment rooms.
"Because of the cost of the system being much lower, and the risk profile being much better, our systems have been profitable in their first year of operation," he said. "That's a significant improvement over centers that have taken 10 or more years to turn that corner."
That heightened profitability comes not only because of the lower initial capital cost, but the smaller staff sizes required to operate the system -- about eight people, all told. The smaller accelerators also draw significantly less power, with Jachinowski saying that electrical costs can be slashed from $1 million annually to about $80,000.
Making proton therapy more accessible benefits patients like Rhea Birusingh, who is undergoing treatments for a tumor near her cranial nerve. Birusingh is the first person to undergo proton therapy at The Marjorie and Leonard Williams Center for Proton Therapy at UF Health Cancer Center-Orlando Health; Orlando Health, affiliated with the UF Health Cancer Center in Gainesville, is among the first centers in the country utilizing Mevion's technology.
Doctors originally told Birusingh that her tumor was clinically inoperable due to its location. But they took a chance on protons. Birusingh, who was pregnant at the time of her diagnosis, had her labor induced at 32 weeks, five days -- and with a newborn baby and a tumor growing at an alarming rate, she felt it was worth the risk.
Before treatment, Birusingh submits herself to a round of scanning so clinicians can get a good look at the affected area. A ton of imaging is performed, and then the protons are beamed directly to her tumor -- and to nowhere else. The entire process, she said, takes about an hour.
Physicians tout the therapy's mitigation of unpleasant side effects, and so far, Birusingh said that's been the case.
"I'm a little tired afterward," she said. "But I'm a new mom, so being tired is my general disposition. Honestly, it's not bad. It's a little bit of numbness under the face, and my skull tissue feels a bit weird. In two to three weeks, I may start to lose my hair."
Despite that, it's a treatment she would recommend.
"I've done extensive research," she said. "Anything that can reduce the side effects is very important. With other treatments, you have so much damage to the normal tissue. I would totally recommend it because of the reduced side effects, and preserving the brain function and capacity. That's the best thing you could hope for.
"I keep telling people I'm blessed," said Birusingh. "I couldn't ask for a better treatment. All I have to do is show up and be on time. Honestly, I'm amazed at the technology -- it's really mind-blowing."
Stuart Klein, executive director of the UF Health Proton Therapy Institute, said the direct financial benefits to the system are slow in coming, but there are plenty of other ways in which the treatment is an economic boon.
"So far there's not a lot of direct return from operating the facility, but it generates a lot of ancillaries," said Klein. "Business comes into the facility. There's a lot of international business, too -- about 10 to 15 percent. That has a halo effect, not just for the hospital but for the city. So from the medical tourism standpoint there's a benefit to the city as well."
From a patient standpoint, the results so far have been encouraging, said Klein. Analyzing data from the treatments offered with the standard-size proton accelerators, he found that the disease progression is similar to what it would be with conventional X-ray therapy, only with reduced side effects: Of more than 6,200 patients treated to date, many of them for prostate cancer, Klein said their long-term prospects look excellent.
"It's become more evident that there's a tremendous benefit in terms of patients' reactions," said Klein.
According to Metz, long-term prospects for the therapy itself look promising, as well.
"It's a very robust technology," said Metz. "Much of it is driven by computers and imaging, so you'll continue to have developments going forward."