A proof of concept study from the University of Texas MD Anderson Cancer Center shows that the episodic cost of care using intensity modulated proton therapy (IMPT) in advanced-stage head and neck cancer is less than that of intensity modulated radiation therapy (IMRT), also known as X-ray or photon therapy.
The study, “Defining the Value of Proton Therapy,” published in Oncology Payers, detailed findings concerning two patients with oropharyngeal cancer. The cost for one patient’s daily IMPT treatment was 2.8 times higher than for the other patient’s daily treatment with IMRT. However, the IMRT patient took more time to begin therapy, which led to higher costs associated with re-consultation and re-imaging. As a result, the method used to measure the costs, what’s called time-driven activity-based costing (TDABC), indicated a 20 percent higher cost from time of initial consultation to the end of IMRT, compared with IMPT.
“We wanted to examine in a very structured way how those processes are done to make sure we’re driving efficiency and quality, and decreasing unnecessary individual encounter costs while still ensuring patients receive high-quality care,” says Steven J. Frank, M.D., medical director, MD Anderson Proton Therapy Center; associate professor of radiation oncology; and senior study author.
TDABC is a costing model that relates the measurement of health care costs to time — including the time
required to perform each medical service, and the level and salary of the hospital staff performing the service. It’s a practice that is widely used in the business world, but not routinely in the U.S. health care industry.
In addition to patient encounter time, the type of cancer treatment also factors heavily into costs — particularly long-term costs — as well as into patient quality of life.
“In this study, we’ve been able to demonstrate that eliminating unnecessary radiation can translate into a reduction in overall cost to the health care system,” says Dr. Frank. “With protons, we can reduce the episodic cost of care by eliminating toxicities that come from X-rays, which result in feeding tube placements, emergency room visits and hospitalizations.”
A larger ongoing study is currently recruiting patients with head and neck cancer. With a goal of 360 patients, the study currently has about 60 people enrolled. Both patients in the small proof of concept study had advanced-stage oropharyngeal cancer.
“Most patients with oropharyngeal cancer are younger adults with a very curable disease. The side-effects from radiation treatment can affect cancer patients for up to 30 or 40 years,” says Dr. Frank. “People with this type of cancer often have young families, they work, and they want to continue to work during treatment and after. When people get X-ray radiation on their tongues, they lose their ability to taste food, they develop painful mouth ulcers and require narcotics, and they can lack the motivation to eat or drink. Lack of caloric intake and weight loss ensue, and feeding tubes are often placed to supplement their nutrition. These patients are struggling during treatment, and protons can help reduce their suffering.”
Dr. Frank uses the example of getting dental X-rays at the dentist’s office. What if the dentist said they were going to take 10 additional X-rays that were not needed? Most people would resist. Radiation exposure from IMRT can put an additional 25 gray (a measurement of the dose of radiation absorbed by the body) into the mouth and tongue when treating oropharyngeal tumors. “Twenty-five gray is equivalent to 5 million dental oral x-rays,” says Dr. Frank. “This unnecessary radiation exposure to the oral cavity and tongue from IMRT can be eliminated with proton therapy.”
In the ongoing trial, TDABC costs will be collected on each patient to help define value. “The cost of delivering care is something many hospital systems have difficulty capturing,” says Dr. Frank. “It is difficult to improve quality systems without knowing how your costs are generated. What happens then is that pricing becomes relatively arbitrary, based on what the reimbursement structure is. So we start valuing things based on the way they’re priced instead of the value they offer.”
Dr. Frank regards protons as one more step in the advancement of radiation therapy. “Over time, we have truly improved the lives of our patients and radiation oncology in general, through these advancements in technology,” he says. “We should regard advanced technology as a way to make us more efficient, provide better care and be innovative. Innovation may cost more in the short term, but may bring inherent value and improve outcomes.
“We aim to define the value of proton therapy associated with the episodic cost of care in order to demonstrate a reduction in overall costs to the health care system.”