Browsing the net I came across this article on proton beam therapy provision in the USA. The introduction of the necessary equipment into clinics in the USA and the subsequent bankruptcy of some is a case study in what’s wrong in US so-called healthcare.
Proton beam therapy is most simply understood a form of “radiotherapy” which uses protons rather than photons (at X-ray frequencies) to destroy tissue, usually tumors. X-rays pass through the body but protons are stopped and produce their most destructive effect where they stop. By adjusting the proton beam, highly accurate and restricted damage is caused to tissue. In comparison, X-rays pass through the tumor and also affect tissue in their path. To reduce damage to normal tissue, the x-rays beams are sent at a series of different angles, so the beams intersect on the tumor.
The nature of proton beam therapy means it is very effective in the destruction of difficult to reach tumors or those close to other structures. Outside of the USA, emphasis was on the one group who could most benefit from this, namely children with brain cancers. Writing prior to the building of facilities in the UK, the NHS would send patients to clinics in other countries like Czechia where there is a clinic in Prague. In 2014, the position was:
The NHS sends patients abroad if their care team thinks they are ideally suited to receive proton beam therapy. Around 400 patients have been sent abroad since 2008 – most of these patients were children.
Proton beam therapy (PBT) equipment is up to 10 times the cost of X-ray equipment but a quick check indicated that the USA has a similar number to the rest of the world combined. Having the latest whizz-bang equipment is of course a big selling point of “American Healthcare” but proton beam therapy was hardly profitable. In February 2014 Scripps Health celebrated the opening of a new center in San Diego. They could treat up to 2,400 patients a year from its affiliated Rady Children's Hospital and the University of California San Diego Health System. Three years later, Scripps filed for bankruptcy protection.
So what went wrong? Well doctors had leapt at the opportunity to use it for “big money” procedures, in particular dealing with prostate cancers. Conventional surgery and radiotherapy runs a significant risk of side effects including bladder problems and impotence due to damage to unaffected areas. PBT offered the chance of eliminating these through its precision, an obvious appeal to men who had been diagnosed with prostate cancer.
Unfortunately the bottom dropped out of that market. Insurance companies refused to authorise the procedure. Other techniques like implanting short half life radioactive “beads” into the tumor or robotic surgery provided lower cost and equally safe and effective treatment. Another big factor was the adoption of alternatives used in other countries. 95% of men with prostate cancer do not die from prostate cancer. Most are slow growing and it is only the aggressive ones which need any treatment at all apart from monitoring — “watchful waiting”. This had long been the practice in other countries but medically induced fear of “the Big C” drove men to seek unnecessary procedures. Even the waiting may now be becoming outdated. Genomics England is sequencing all new cancers’ genomes and analysing the results with data from its 100,000 Genome Project. Expanding this to a million genomes sequenced will improve its accuracy. This should enable doctors to distinguish genetic errors that cause aggressive prostate cancers
These changes meant that between 2012 and 2015 the number of patients treated in the USA for prostate cancer with PBT was static at around 2,300 cases whereas the total number of patients rose from 5377 to just over 7000. A number of PBT clinics simply did not have enough patients being referred for them to be economic.
While insurance companies are one problem, a far more serious one concerns oncologists themselves.
If proton treatment centers each treated 500 patients per year, there should be enough patients to support 100 centers across the country. (That's 50,000 divided by 500, if you're keeping score.) Why, then, are so many of them facing such harsh economic realities?
One reason is that insurers are not covering most proton therapy. But the other explanation is the disturbing one: Radiation oncologists don't want to give away their income-producing patients.
"No provider is willing to give up patients, even though they know the long-term toxicity and morbidity of the patient they are treating with conventional therapy is bound to be higher," Palta said.
Yes, American doctors are not referring patients for what could be a better and safer treatment with fewer side effects, because they will not make money out of it. In contrast, “socialist” health systems assess treatments on the basis of clinical need and best practice.
NHS England had a low power unit for treating eye cancers and opened a full setup last year. Another center is planned to open in 2020 but both will take over a year to become fully operational. In the meantime suitable patients will continue to be sent abroad. NHS England has introduced guidelines for the assessment of patients and investigations into which cancers are best treated with PBT. (Again, this may hopefully be reduced by more targetted drugs identified by genome sequencing). Because of the cost, local commissioning bodies, which contract and pay for services provided under the NHS, need to spend money in the most effective way. It’s highly unlikely that PBT treatment for prostate cancers would be approved at all. Note that these proposals are public and any patient refused PBT by their local commissioning group could seek judicial review if they failed to comply with the guidelines. No reliance on the vagaries of the insurance companies’ death panels run by bean-counters. (The NHSs in Scotland, Wales and Northern Ireland will be able to use the English facilities and will likely adopt similar guidelines to select eligible patients.)
So the lessons which point towards why US healthcare is more expensive and has worse outcomes.
- Providers rush to install the latest highly expensive equipment with little or no regard to real demand for the facility.
- Many oncologists promote the non-use of this equipment for personal financial reasons even when referral would produce the best outcome for their patient.
- Doctors encourage patients to undergo procedures for which there is no clinical proof of its effectiveness or benefit over cheaper conventional treatment.
- Insurance companies refuse the use of highly expensive therapies because they are not shown to be effective, reducing the “throughput” of patients and therefore increasing the cost of the treatment per patient.
- Universal systems may be slow to build such facilities locally but make the treatment available elsewhere on the basis of clinical need.
Finally, it may be useful to consider why the NHS would send patients abroad for PBT. As I mentioned, destruction of tissue can be far more localised. In patients with brain tumors, damaging surrounding tissue can result in cognitive or motor impairments. For a universal system, a treatment 10x as expensive can save money from not having to treat and provide support for a damaged patient over many years. For an insurance company, it eats into that year’s profits.
Wednesday, Jan 23, 2019 · 2:16:09 PM +00:00 · Lib Dem FoP
Quite co-incidentally, the day after I wrote this, the first UK PBT unit started to admit patients, one of the first is a 15 year old.
Fifteen-year-old Mason Kettley, who has a rare brain cancer, is about to become one of the first UK patients to have proton-beam therapy, at a new dedicated treatment centre.
He is starting treatment at the £125m centre at Manchester's Christie hospital. ….
An MRI scan showed he had a rare pilomyxoid astrocytoma brain tumour. It couldn't be operated on because of a risk of blindness and other "catastrophic" complications.
His oncologist explained why he was a suitable patient and other reasons why PBT was preferable for him.
"For Mason, in comparison to conventional radiotherapy, PBT should carry a lower risk of some important long-term side-effects of treatment - particularly effects on short-term memory and learning ability - and the risk over the next eight decades of the radiation causing other tumours.
"This is particularly important for children and teenagers with curable tumours, who will survive decades after treatment and are at much greater risk of serious long-term effects of treatment than adults.
Extra short term costs vs 80 years of managing side-effects; a no-brainer (if you will excuse the expression) for a service that can take the long term view of costs.