Proton therapy centers are being built around the country, and one of the companies leading this effort is ProCure, a company dedicated to improving the lives of patients with cancer by increasing access to proton therapy. Since 2005, ProCure has developed several centers and more are underway. Oncology Net Guide (ONG) recently had the opportunity to interview John Cameron, PhD, founder, chairman, and president of the ProCure Treatment Centers to gain insights on proton therapy from one of its biggest proponents.
ONG: Building proton beam centers is a costly endeavor, with start-up fees averaging $125 million. A considerable portion of the costs appears to arise from the need to build a large facility, measuring approximately 92,000 square feet, to house the giant particle accelerator. Has any progress been made in decreasing the size of these accelerators and in reducing costs?
Dr Cameron: The accelerator itself is generally not the largest component of the equipment. That, in fact, is the gantry that transports the proton beam around the patient. We already see new technology being implemented that will dramatically decrease both accelerator size and weight over the next 5 years with commensurate decrease in their cost. That said, proton therapy is a sophisticated therapy that requires a complex construction process, large precision instruments, and state-of-the-art information technology. ProCure has simplified and standardized the complex process of developing proton therapy and brought construction and start-up costs down by about 25% in just the past 3 years, and we’ve identified opportunities to bring these costs down even further. This is not unlike other sophisticated treatments where the cost of equipment, for example, will decrease as it is more widely used and developed.
One of ProCure’s most significant advances, which has reduced the size and cost of our centers, is the development of a new treatment technology using two beam lines in the treatment room—the Inclined Beam Room. The Inclined Beam Room is only a fraction of the size of a gantry, the industry standard, allowing the footprint of ProCure Proton Therapy Centers to be much smaller at 60,000 square feet and less costly. The Inclined Beam Room can treat 80% of the tumors treated with a gantry at only 50% of the capital cost. The ProCure Proton Therapy Center in Oklahoma City is the first center in the world with this unique innovation.
ONG: Although the costs of administering proton therapy may be higher than that of conventional X-ray radiation, are there any long- term cost savings?
Dr Cameron: When you discuss the cost of proton therapy and compare it with the most likely alternative, X-ray therapy, you must consider the cost of treating the short- and long- term side effects from conventional radiation therapy. These effects are not insignificant and all have an associated cost. Because proton therapy causes less damage to healthy tissue, side effects are greatly reduced. As a result, proton therapy limits productivity loss for both the worker and the employer. Short-term side effects such as nausea, vomiting, and loss of energy are reduced or eliminated, and workers can receive treatment and return to work the same day. Over the long-term, proton therapy reduces the chances of secondary cancers and tumor recurrence, saving costs associated with additional cancer treatment.
ONG: Do you think proton therapy will eventually replace conventional X-ray radiation therapy?
Dr Cameron: The downside of radiation is that it is inherently destructive; radiation damages healthy tissue on its way to the target and as it exits the body. As professor Herman Suit famously said many years ago, “there is never a good reason to irradiate healthy tissue.” Proton therapy is more precise and far less damaging. It is not yet a replacement for most radiation treatments, but rather an important and powerful complement to traditional therapy.
Proton therapy also presents treatment options for some patients who cannot be treated with X-ray radiation. For example, proton therapy can be used to treat tumors that recur, while standard radiation therapy cannot, and when patients who have X-ray radiation reach a point where no further therapy can be tolerated, proton therapy may be an option. Patients prescribed chemotherapy may also benefit substantially from having concurrent proton radiation therapy because proton treatments are much less toxic than conventional therapy.
ONG: How does ProCure decide where to build a proton therapy center?
Dr Cameron: Our mission is to make proton therapy available in more locations so patients have access closer to home. We look for radiation oncology practices and hospitals or health systems that have a reputation for innovation and adopting advanced therapies and technologies, and are dedicated to finding the best and most appropriate medical care possible for their patients. The radiation oncologists and hospitals we have joined with have an overriding commitment to their cancer patients, which perfectly aligns with our mission.
ONG: Can you briefly discuss what went into building the ProCure Proton Therapy Center in Oklahoma City, which is the latest center to open? Were there any hurdles that had to be overcome and were any lessons learned along the way?
Dr Cameron: The ProCure Proton Therapy Center in Oklahoma City was built in a world-record 27 months, and we were able to reduce the cost of building the center through design and technological innovations. We accomplished this because our skilled team of proton therapy experts applied all of the “lessons learned” from their experience operating and building other proton and medical treatment facilities to the Oklahoma center. In turn, we’re already applying lessons learned from the Oklahoma center to further streamline the building process on our center under construction near Chicago and will do the same for our other centers under development in New Jersey, Michigan, and Florida.
An obstacle other proton centers have encountered that we were able to avoid is staffing their centers and training those staff. Before we broke ground in Oklahoma City, we created the ProCure Training and Development Center (TDC), which opened in 2008 and is now the world’s only facility dedicated exclusively to proton therapy training. Other centers have had to use their treatment facilities to train their staff, which has delayed their ability to treat patients by many months. We trained the entire medical professional and administrative staff of the Oklahoma center at TDC before the treatment center was completed, allowing us to begin treating patients as soon as our equipment was commissioned.
The TDC offers before-the-job training, ensuring that patient treatments can begin in an efficient and safe manner. The TDC provides fully simulated treatment rooms identical to those found in our proton center. Training includes a concentration on the necessary sophisticated technical skills and the “softer” skills, such as empathy training, that provide comfort and assurance to patients. The TDC also has treatment planning areas, an immobilization device development area, and lecture rooms.
ONG: Have you encountered any patients reluctant to receive proton therapy, namely, do some think of this modality as experimental?
Dr Cameron: We have not found this to be the case. Patients seek proton therapy because they are referred by their physicians or learn about protons through their own research and decide to explore it as an option. Proton therapy has been used for more than 50 years, and it was endorsed by the Centers for Medicare and Medicaid almost a decade ago; these facts are reported in most of the literature and Websites that discuss protons. This therapy is also covered by many insurance plans, Medicare, and state Medicaid plans, which is another reassurance for patients.
The major issue we’ve faced is that the majority of patients who could benefit from this highly effective cancer treatment aren’t able to receive it because treatment availability is still limited, but this is an issue we are working on resolving. We are also committed to progressing the knowledge and research regarding proton therapy, and short-term and long-term outcome data will be collected for every patient treated at a ProCure center.
ONG:What should medical oncologists know about proton beam therapy?
Dr Cameron: Proton therapy has proven efficacy for the treatment of specific solid tumors and provides an additional treatment option for patients and clinicians. Research is also underway for an expanding numbers of tumors.
Because proton therapy is characterized by less radiation being delivered to healthy tissue and critical structures adjacent to the treatment volume, as well as the ability to deposit a larger dose in the targeted volume, its most significant benefits are less short- and long-term side effects versus X-ray radiation. Medical oncologists, in particular, should be aware that patients prescribed chemotherapy can have proton therapy because these treatments are much less toxic than standard radiation, enabling proton treatment to be more readily used concurrently with chemotherapy.
These factors can result in a number of benefits, including improved tumor control, reduced incidence of secondary tumors, fewer treatment- related short- and long-term side effects, and extended survival times.
ONG: Has the research shown a survival benefit with proton therapy versus X-ray therapy?
Because radiation oncology is a physical science, the benefits of one versus the other can be modeled to identify the exposure of radiation to healthy tissue. Research at MD Anderson
has shown that proton therapy may decrease the rates of secondary radiation-associated cancer by between 26% and 39% compared with intensity-modulated radiation therapy.
A retrospective study
from Massachusetts General Hospital found significantly lower secondary cancer rates with a combination of X-ray radiation and protons (6.4%) compared with the national average with X-rays (12.8%). In addition, patients who received only proton therapy had no secondary malignancies.