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August 28, 2013, 8:09 p.m. ET

Prostate-Cancer Therapy Comes Under Attack

Some Insurers Stop Covering Expensive Proton Beams to Battle Prostate Cancer

By RON WINSLOW and TIMOTHY W. MARTIN
 
 
Health insurers are pushing back against one of medicine's most expensive technologies amid growing evidence it may not be better for patients than cheaper options.
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At least three major insurers have recently decided to stop covering proton beam therapy for early stage prostate cancer or are reviewing their policy, saying that while it is an effective treatment, it is much less cost-effective when compared to the price of comparable treatments.

Proton beam therapy is one of the most expensive prostate cancer treatments, but there’s no evidence it’s better than others and some insurers are starting to tell doctors they will no longer pay for it. Ron WInslow reports. Photo: Getty Images.
 

The moves come amid ongoing concern about U.S. health-care costs and a land-rush atmosphere among leading medical centers to acquire proton beam technology.
 

The technology's proponents say its precision spares healthy tissue from bombardment by radiation, reducing the significant side effects associated with other radiation treatments.

For at least a decade, health insurers went along. The federal Medicare program pays more than $32,000 for the procedure, a recent study found, compared with about $19,000 for more conventional radiation options.
 

But that's starting to change. At least three major insurers have recently stopped covering the procedure or say they're reviewing it, citing a lack of evidence that it works better or causes fewer complications than standard radiation.
 

This week, Blue Shield of California sent letters to about 300 radiation oncology and urology practices in the state, advising them that beginning at the end of October, it will no longer cover proton-beam therapy for early-stage prostate cancer. "The preponderance of medical evidence clearly shows that the treatment has about the same clinical outcomes as other forms of radiation, but it's a lot more expensive," said Marcus Thygeson, senior vice president and chief health officer at Blue Shield of California. "Because it's not cost effective, we're not going to cover it."
 

In the past two years, the insurer approved 1,750 patients for prostate-cancer radiation therapy, and about 100, or nearly 6%, received proton beam therapy.
 

The insurer is joining Aetna Inc., AET +1.54% the third-largest U.S. insurer based on enrollment, which stopped covering the procedure for prostate cancer on Aug. 1. The change is "designed to help our members access safe, effective and cost-efficient therapies," said Jim Cross, Aetna's head of medical policy and operations.
 

Cigna Corp. CI +0.75% plans to review its policy later this year. Meantime, Regence, a Blue Cross Blue Shield insurer that operates in four Northwestern states, switched to a no-coverage policy three years ago. Highmark Inc., Pittsburgh, and Blue Cross and Blue Shield of Kansas City have long-standing positions against it.
 

But others, like WellPoint Inc., WLP +0.74% the nation's second largest insurer, continue to cover it while negotiating down the costs of treatment. "In some locations, the cost is now comparable to other forms of radiation therapy," said Kristin Binns, a spokeswoman for WellPoint, which considers it to be "medically necessary" for therapy under certain situations.
 

Medicare, the most influential insurer, continues to pay for the technology. A spokesman for the Centers for Medicare and Medicaid Services declined to comment on whether the agency's coverage policy would be revisited. Medicare payments for proton-beam therapy are falling because the hospitals billing for the services report lower costs.
 

Amitabh Chandra, professor of public policy at Harvard University and a critic of proton beam, said he's "encouraged" by the steps some insurers are taking, but as long as Medicare pays for the therapy, it will be difficult for most insurers to deny coverage. "It's an important move in the right direction," he said. But "one would have to be incredibly optimistic to think that this is enough to really put the squeeze on this technology."
 

Eleven proton-beam facilities currently operate in the U.S. At least 15 more are in development, according to the National Proton Therapy Association, including two for the Mayo Clinic at its campuses in Minnesota and Arizona, the Scripps Proton Therapy Center in San Diego, and two within about 50 miles of Washington, D.C.
 

The technology's makers include Varian Medical Systems Inc., VAR +0.42% Ion Beam Applications of Belgium and Hitachi Ltd. 6501.TO -0.17%
 

More than 200,000 U.S. men are diagnosed with prostate cancer each year. Most such tumors are slow growing and not life threatening, but some 28,000 die of the disease annually. That prompts many men to choose aggressive treatmentssurgery or radiation—despite side effects that can include incontinence and impotence.
 

The standard radiation treatment for early-stage prostate cancer is IMRT, or intensity modulated radiation therapy, a computer-guided approach using X-rays that is also intended to minimize healthy-tissue damage.
 

But proponents argue that the proton-beam technique targets the tumor more precisely, reducing complications. The therapy is also used for other, generally rarer tumors, including pediatric brain cancer, eye, bladder and spinal cord tumors, where it's use is less controversial.
 

So far, assertions about proton beam's superiority in treating prostate cancer haven't been backed up by medical evidence. "Because of all the claims that have been made on behalf of proton treatment and the sheer enormity of these facilities, the cost has risen to the level where we need to scrutinize how much better proton beam is," said James B. Yu, a Yale University radiation oncologist.
 

A study he led, which was based on Medicare-claims data and was published late last year, found proton-beam therapy was associated with fewer complications in the first six months after treatment but the benefit vanished by 12 months.
 

The findings were among the triggers for Blue Shield of California's review of its coverage policy. Dr. Thygeson said another factor was that the most authoritative cancer-treatment guidelines, citing a lack of relevant clinical-trial data, say the procedure "is not recommended for routine use at this time."
 

The decision reflects "a very short-term mind-set" that is overly concerned with the treatment's price tag, said Chris Van Gorder, chief executive of Scripps Health, which is opening the San Diego facility later this year. "This is an example of an insurance company injecting themselves in the middle and making a decision as to what's best for the patient and their physician."
 

Demand for proton therapy is "softer" now than it was in 2011, because influential research and subsequent policy shifts by physician groups have challenged claims of an advantage, said Daniel Fontoura, the senior vice president overseeing the proton program at Loma Linda University Medical Center in California.
 

Cost of treatment is the main factor holding back further adoption of proton therapy, said Leonard Arzt, executive director of the National Association for Proton Therapy, a nonprofit advocacy group. "There would be no debate if costs were the same as conventional X-ray radiation."


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