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Gupta A, Subramani V, Kumar R, Kareem R, Vishwanathan B, Sharma DN. Revolutionizing cancer treatment in India: Evaluating the unmet need, economics, and a roadmap for project implementation of particle therapy. Cancer 2024; 130:2528-2537. [PMID: 38373062 DOI: 10.1002/cncr.35233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 01/01/2024] [Accepted: 01/17/2024] [Indexed: 02/21/2024]
Abstract
INTRODUCTION This study aims to quantitatively assess eligible patients and project the demand for particle therapy facilities in India from 2020 to 2040. In addition, an economic analysis evaluates the financial feasibility of implementing this technology. The study also examines the prospective benefits and challenges of adopting this technology in India. METHODOLOGY Cancer incidence and projected trends were analyzed for pediatric patients using the Global Childhood Cancer microsimulation model and adult patients using the Globocan data. Economic cost evaluation is performed for large-scale combined particle (carbon and proton-three room fixed-beam), large-scale proton (one gantry and two fixed-beam), and small-scale proton (one gantry) facility. RESULTS By 2040, the estimated number of eligible patients for particle therapy is projected to reach 161,000, including approximately 14,000 pediatric cases. The demand for particle therapy facilities is projected to rise from 81 to 97 in 2020 to 121 to 146 by 2040. The capital expenditure is estimated to be only 3.7 times that of a standard photon linear accelerator over a 30-year period. Notably, the treatment cost can be reduced to USD 400 to 800 per fraction, substantially lower than that in high-income countries (USD 1000 to 3000 per fraction). CONCLUSION This study indicates that, in the Indian scenario, all particle therapy models are cost-beneficial and feasible, with large-scale proton therapy being the most suitable. Despite challenges such as limited resources, space, a skilled workforce, referral systems, and patient affordability, it offers substantial benefits. These include the potential to treat many patients and convenient construction and operational costs. An iterative phased implementation strategy can effectively overcome these challenges, paving the way for the successful adoption of particle therapy in India. PLAIN LANGUAGE SUMMARY In India, the number of eligible patients benefiting from high-precision particle therapy technology is projected to rise till 2040. Despite high upfront costs, our study finds the long-term feasibility of all particle therapy models, potentially offering a substantial reduction in treatment cost compared to high-income countries. Despite challenges, India can succeed with an iterative phased approach.
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Affiliation(s)
- Anil Gupta
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - V Subramani
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi & National Cancer Institute, Jhajjar, Haryana, India
| | - Rishabh Kumar
- Department of Radiation Oncology, Amrita Hospital, Faridabad, India
| | - Rafi Kareem
- Department of Medical Physics, Heidelberg Ion Therapy Center, Heidelberg, Germany
| | | | - Daya Nand Sharma
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi & National Cancer Institute, Jhajjar, Haryana, India
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Mendenhall NP. Bringing proton therapy to India: The recent article from Gupta et al. on revolutionizing cancer treatment in India. Cancer 2024; 130:2413-2415. [PMID: 38676930 DOI: 10.1002/cncr.35320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
Gupta et al. have outlined a rational approach for bringing the promising emerging technology of proton therapy to India. Their roadmap is based on consensus‐driven prioritization systems (American Society for Radiation Oncology guidelines), careful assessment of population needs, and careful consideration of economics.
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Affiliation(s)
- Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
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Lillo S, Mirandola A, Vai A, Camarda AM, Ronchi S, Bonora M, Ingargiola R, Vischioni B, Orlandi E. Current Status and Future Directions of Proton Therapy for Head and Neck Carcinoma. Cancers (Basel) 2024; 16:2085. [PMID: 38893203 PMCID: PMC11171191 DOI: 10.3390/cancers16112085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024] Open
Abstract
The growing interest in proton therapy (PT) in recent decades is justified by the evidence that protons dose distribution allows maximal dose release at the tumor depth followed by sharp distal dose fall-off. But, in the holistic management of head and neck cancer (HNC), limiting the potential of PT to a mere dosimetric advantage appears reductive. Indeed, the precise targeting of PT may help evaluate the effectiveness of de-escalation strategies, especially for patients with human papillomavirus associated-oropharyngeal cancer (OPC) and nasopharyngeal cancer (NPC). Furthermore, PT could have potentially greater immunogenic effects than conventional photon therapy, possibly enhancing both the radiotherapy (RT) capability to activate anti-tumor immune response and the effectiveness of immunotherapy drugs. Based on these premises, the aim of the present paper is to conduct a narrative review reporting the safety and efficacy of PT compared to photon RT focusing on NPC and OPC. We also provide a snapshot of ongoing clinical trials comparing PT with photon RT for these two clinical scenarios. Finally, we discuss new insights that may further develop clinical research on PT for HNC.
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Affiliation(s)
- Sara Lillo
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.C.); (S.R.); (M.B.); (R.I.); (B.V.); (E.O.)
| | - Alfredo Mirandola
- Medical Physics Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.); (A.V.)
| | - Alessandro Vai
- Medical Physics Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.); (A.V.)
| | - Anna Maria Camarda
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.C.); (S.R.); (M.B.); (R.I.); (B.V.); (E.O.)
| | - Sara Ronchi
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.C.); (S.R.); (M.B.); (R.I.); (B.V.); (E.O.)
| | - Maria Bonora
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.C.); (S.R.); (M.B.); (R.I.); (B.V.); (E.O.)
| | - Rossana Ingargiola
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.C.); (S.R.); (M.B.); (R.I.); (B.V.); (E.O.)
| | - Barbara Vischioni
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.C.); (S.R.); (M.B.); (R.I.); (B.V.); (E.O.)
| | - Ester Orlandi
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy; (A.M.C.); (S.R.); (M.B.); (R.I.); (B.V.); (E.O.)
- Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
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Burus T, VanHelene AD, Rooney MK, Lang Kuhs KA, Christian WJ, McNair C, Mishra S, Paulino AC, Smith GL, Frank SJ, Warner JL. Travel-Time Disparities in Access to Proton Beam Therapy for Cancer Treatment. JAMA Netw Open 2024; 7:e2410670. [PMID: 38758559 PMCID: PMC11102024 DOI: 10.1001/jamanetworkopen.2024.10670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/11/2024] [Indexed: 05/18/2024] Open
Abstract
Importance Proton beam therapy is an emerging radiotherapy treatment for patients with cancer that may produce similar outcomes as traditional photon-based therapy for many cancers while delivering lower amounts of toxic radiation to surrounding tissue. Geographic proximity to a proton facility is a critical component of ensuring equitable access both for indicated diagnoses and ongoing clinical trials. Objective To characterize the distribution of proton facilities in the US, quantify drive-time access for the population, and investigate the likelihood of long commutes for certain population subgroups. Design, Setting, and Participants This population-based cross-sectional study analyzed travel times to proton facilities in the US. Census tract variables in the contiguous US were measured between January 1, 2017, and December 31, 2021. Statistical analysis was performed from September to November 2023. Exposures Drive time in minutes to nearest proton facility. Population totals and prevalence of specific factors measured from the American Community Survey: age; race and ethnicity; insurance, disability, and income status; vehicle availability; broadband access; and urbanicity. Main Outcomes and Measures Poor access to proton facilities was defined as having a drive-time commute of at least 4 hours to the nearest location. Median drive time and percentage of population with poor access were calculated for the entire population and by population subgroups. Univariable and multivariable odds of poor access were also calculated for certain population subgroups. Results Geographic access was considered for 327 536 032 residents of the contiguous US (60 594 624 [18.5%] Hispanic, 17 974 186 [5.5%] non-Hispanic Asian, 40 146 994 [12.3%] non-Hispanic Black, and 195 265 639 [59.6%] non-Hispanic White; 282 031 819 [86.1%] resided in urban counties). The median (IQR) drive time to the nearest proton facility was 96.1 (39.6-195.3) minutes; 119.8 million US residents (36.6%) lived within a 1-hour drive of the nearest proton facility, and 53.6 million (16.4%) required a commute of at least 4 hours. Persons identifying as non-Hispanic White had the longest median (IQR) commute time at 109.8 (48.0-197.6) minutes. Multivariable analysis identified rurality (odds ratio [OR], 2.45 [95% CI, 2.27-2.64]), age 65 years or older (OR, 1.09 [95% CI, 1.06-1.11]), and living below the federal poverty line (OR, 1.22 [1.20-1.25]) as factors associated with commute times of at least 4 hours. Conclusions and Relevance This cross-sectional study of drive-time access to proton beam therapy found that disparities in access existed among certain populations in the US. These results suggest that such disparities present a barrier to an emerging technology in cancer treatment and inhibit equitable access to ongoing clinical trials.
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Affiliation(s)
- Todd Burus
- Markey Cancer Center, University of Kentucky, Lexington
| | | | - Michael K. Rooney
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Krystle A. Lang Kuhs
- Markey Cancer Center, University of Kentucky, Lexington
- Department of Epidemiology & Environmental Health, College of Public Health, University of Kentucky, Lexington
| | - W. Jay Christian
- Department of Epidemiology & Environmental Health, College of Public Health, University of Kentucky, Lexington
| | - Christopher McNair
- Department of Cancer Biology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sanjay Mishra
- Lifespan Cancer Institute, Rhode Island Hospital, Providence
- Center for Clinical Cancer Informatics and Data Science, Legorreta Cancer Center, Brown University, Providence, Rhode Island
| | - Arnold C. Paulino
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Grace L. Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Steven J. Frank
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Jeremy L. Warner
- Lifespan Cancer Institute, Rhode Island Hospital, Providence
- Center for Clinical Cancer Informatics and Data Science, Legorreta Cancer Center, Brown University, Providence, Rhode Island
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Lin J, Shriver CD, Zhu K. Survival among lung cancer patients: comparison of the U.S. military health system and the surveillance, epidemiology, and end results (SEER) program by health insurance status. Cancer Causes Control 2024; 35:21-31. [PMID: 37532916 DOI: 10.1007/s10552-023-01765-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/19/2023] [Indexed: 08/04/2023]
Abstract
PURPOSE The U.S. military health system (MHS) provides beneficiaries with universal health care while health care access varies in the U.S. general population by insurance status/type. We divided the patients from the U.S. general population by insurance status/type and compared them to the MHS patients in survival. METHODS The MHS patients were identified from the Department of Defense's Automated Central Tumor Registry (ACTUR). Patients from the U.S. general population were identified from the Surveillance, Epidemiology, and End Results (SEER) program. Multivariable Cox regression analysis was conducted to compare different insurance status/type in SEER to ACTUR in overall survival. RESULTS Compared to ACTUR patients with non-small cell lung cancer (NSCLC), SEER patients showed significant worse survival. The adjusted hazard ratios (HRs) were 1.08 [95% Confidence Interval (CI) = 1.03-1.13], 1.22 (95% CI = 1.16-1.28), 1.40 (95% CI = 1.33-1.47), 1.50 (95% CI = 1.41-1.59), for insured, insured/no specifics, Medicaid, and uninsured patients, respectively. The pattern was consistently observed in subgroup analysis by race, gender, age, or tumor stage. Results were similar for small cell lung cancer (SCLC), although they were only borderline significant in some subgroups. CONCLUSION The survival advantage of patients receiving care from a universal health care system over the patients from the general population was not restricted to uninsured or Medicaid as expected, but was present cross all insurance types, including patients with private insurance. Our findings highlight the survival benefits of universal health care system to lung cancer patients.
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Affiliation(s)
- Jie Lin
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, 6720A Rockledge Drive, Suite 310, Bethesda, MD, 20817, USA.
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, 20817, USA.
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA.
| | - Craig D Shriver
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, 6720A Rockledge Drive, Suite 310, Bethesda, MD, 20817, USA
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
| | - Kangmin Zhu
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, 6720A Rockledge Drive, Suite 310, Bethesda, MD, 20817, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, 20817, USA
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
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Karian V, Morton H, Schefter ZJ, Smith A, Rogan H, Morse B, LeBel A. OnabotulinumtoxinA for Pediatric Migraine. Pain Manag Nurs 2023; 24:610-616. [PMID: 37183070 DOI: 10.1016/j.pmn.2023.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/08/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Migraine is a painful, prevalent, and problematic condition among children. Children need access to safe and effective treatment options to alleviate the impact of this chronic condition on their wellbeing. CLINICAL IMPLICATIONS Nurses have a crucial role in supporting patient access to BTX-A. Given the results of this and other studies demonstrating the safety and efficacy of BTX-A in children, nurses can support policy change for health plans to fund this intervention for pediatric migraineurs. Allowing children to receive the safe and effective BTX-A injections will lessen the already significant impact of chronic migraine on their physical, emotional and mental health. Nurses can also play a key role in providing education to patients regarding safe administration of BTX-A for migraine. AIM The objective of this study was to define the experiences, effects, and clinical response of children to onabotulinumtoxinA (BTX-A) for migraine prevention. METHODS Clinical documentation for patients aged 13-17 years presenting for BTX-A treatment for chronic migraine between 2016-2022 in a community-based specialty clinic within a large, urban, pediatric academic medical center were included. A series of one-way repeated measures (analysis of variance [ANOVA]) were conducted to compare headache frequency, severity, and duration at baseline, and following first and second injections of BTX-A. RESULTS Of 32 eligible participants, administration of BTX-A demonstrated a decrease in headache frequency and severity. Participants reported nearly seven fewer headache days per month. Participants reported neck stiffness, fever or flu-like symptoms, fatigue, and worsening pain following BTX-A administration. CONCLUSIONS Pediatric migraineurs need therapies that are safe, effective, and accessible. BTX-A was a safe and effective treatment for migraine among the children included in this study.
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Affiliation(s)
- Victoria Karian
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Hannah Morton
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Zoë J Schefter
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Allison Smith
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Hannah Rogan
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Brenna Morse
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; School of Nursing, MGH Institute of Health Professions, Boston, Massachusetts.
| | - Alyssa LeBel
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
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Choi JI, Simone CB, Lozano A, Frank SJ. Advances and Challenges in Conducting Clinical Trials With Proton Beam Therapy. Semin Radiat Oncol 2023; 33:407-415. [PMID: 37684070 PMCID: PMC10503212 DOI: 10.1016/j.semradonc.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Advances in proton therapy have garnered much attention and speculation in recent years as the indications for proton therapy have grown beyond pediatric, prostate, spine, and ocular tumors. To achieve and maintain consistent access to this cancer treatment and to ensure the future viability and availability of proton centers in the United States, a call for evidence has been heard and answered by proton radiation oncologists. Answers provided in this review include the evolution of proton therapy research, rationale for proton clinical trial design, challenges in and barriers to the conduct of proton therapy research, and other unique considerations for the study of proton therapy.
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Affiliation(s)
- J Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY.; New York Proton Center, New York, NY..
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY.; New York Proton Center, New York, NY
| | - Alicia Lozano
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Tech, Roanoke, VA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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McDonald MW, Bates JE, McCall NS, Goyal S, Liu Y, Rudra S, Remick JS, Tian S, El-Deiry MW, Saba NF, Stokes WA, Swinney E. Insurance Authorization and Access to Proton Therapy for Patients With Head and Neck Cancers. Int J Radiat Oncol Biol Phys 2023; 116:404-412. [PMID: 36889515 DOI: 10.1016/j.ijrobp.2023.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 02/17/2023] [Accepted: 02/17/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE We evaluated our institutional experience to assess potential racial inequities in insurance coverage for proton therapy in patients with head and neck (HN) cancer. METHODS AND MATERIALS We examined the demographics of 1519 patients with HN cancer seen in consultation at our HN multidisciplinary clinic (HN MDC) and 805 patients for whom a proton insurance authorization was sought (PAS) from January 2020 to June 2022. The prospects for proton therapy insurance authorization were prospectively noted based on each patient's ICD-10 (International Classification of Diseases, 10th Revision) diagnosis code and their specific insurance plan. Proton-unfavorable (PU) insurance were those plans whose policy describes proton beam therapy as "experimental" or "not medically necessary" for the given diagnosis. RESULTS For patients seen in our HN MDC, Black, Indigenous, and people of color (BIPOC) were significantly more likely to have PU insurance than non-Hispanic White (NHW) patients (24.9% vs 18.4%, P = .005). In multivariable analysis including race, average income of residence ZIP code, and Medicare eligibility age, BIPOC patients had an odds ratio of 1.25 for PU insurance (P = .041). In the PAS cohort, while there was no difference in the percentage of patients receiving insurance approval for proton therapy between NHW and BIPOC populations (88% vs 88.2%, P = .80), for patients with PU insurance, the median time to determination was significantly longer (median, 15.5 days), and the median time to start any radiation of any modality was longer (46 vs 35 days, P = .08). Compared with NHW patients, the median time from consultation to start of radiation therapy was longer for BIPOC patients (37 vs 43 days, P = .01). CONCLUSIONS BIPOC patients were significantly more likely to have insurance plans unfavorable to proton therapy coverage. These PU insurance plans were associated with a longer median time to determination, a lower approval rate for proton therapy, and a longer time to start radiation of any modality.
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Affiliation(s)
- Mark W McDonald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia.
| | - James E Bates
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Neal S McCall
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Subir Goyal
- Biostatistics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Yuan Liu
- Biostatistics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, Georgia; Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Soumon Rudra
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Jill S Remick
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Mark W El-Deiry
- Department of Otolaryngology Head and Neck Surgery, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Nabil F Saba
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - William A Stokes
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Erica Swinney
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
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Merrill JR, Flitcroft MA, Miller T, Beichner B, Clarke CN, Maduekwe UN, Wang TS, Dream S, Christians KK, Gamblin TC, Evans DB, Kothari AN. Patterns of Unnecessary Insurer Prior Authorization Denials in a Complex Surgical Oncology Practice. J Surg Res 2023; 288:269-274. [PMID: 37037166 DOI: 10.1016/j.jss.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/17/2023] [Accepted: 03/09/2023] [Indexed: 04/12/2023]
Abstract
INTRODUCTION Insurance prior authorization (PA) is a determination of need, required by a health insurer for an ordered test/procedure. If the test/procedure is denied, a peer-to-peer (P2P) discussion between ordering provider and payer is used to appeal the decision. The objective of this study was to measure the number and patterns of unnecessary PA denials. METHODS This was a retrospective review at a quaternary cancer center from October 2021 to March 2022. Included were all patients with outpatient imaging orders for surgical planning or surveillance of gastrointestinal, endocrine, or skin cancer. Primary outcome was unnecessary initial denial (UID) defined as an order that required preauthorization, was initially denied by the insurer, and subsequently overturned by P2P. RESULTS Nine hundred fifty seven orders were placed and 419 required PA (44%). Of tests requiring authorization, 55/419 (13.1%) were denied. Variability in the likelihood of initial denial was seen across insurers, ranging from 0% to 57%. Following P2P, 32/55 were overturned (58.2% UID). The insurers most likely to have a UID were Aetna (100%), Anthem (77.8%), and Cigna (50.0%). UID was most common for gastrointestinal (58.9%) and endocrine (58.3%) cancers. Average P2P was 33.5 min (interquartile range 28-40). CONCLUSIONS The majority of imaging studies initially denied were overturned after P2P. If all UIDs were eliminated, this would represent 108 less P2P discussions with an estimated time-savings of 60.3 h annually within a high-volume surgical oncology practice. Combined personnel costs to the health systems and stress on patients with cancer due to image-associated PAs and P2P appear hard to justify.
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Affiliation(s)
- Jennifer R Merrill
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Madelyn A Flitcroft
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tracy Miller
- Enterprise Registration, Froedtert Health, Menomonee Falls, Wisconsin
| | - Brien Beichner
- Enterprise Registration, Froedtert Health, Menomonee Falls, Wisconsin
| | - Callisia N Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ugwuji N Maduekwe
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tracy S Wang
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sophie Dream
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kathleen K Christians
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - T Clark Gamblin
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Douglas B Evans
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anai N Kothari
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Trotter J, Lin A. Advances in Proton Therapy for the Management of Head and Neck Tumors. Surg Oncol Clin N Am 2023; 32:587-598. [PMID: 37182994 DOI: 10.1016/j.soc.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Proton therapy (PBRT) is a form of external beam radiotherapy with several dosimetric advantages compared with conventional photon (x-ray) radiotherapy. Unlike x-rays, protons deposit most of their dose over a finite range, with no exit dose, in a pattern known as the Bragg peak. Clinically, this can be exploited to optimize dose to tumors while delivering a lower integral dose to normal tissues. However, the optimal role of PBRT is not as well-defined as advanced x-ray-based techniques such as intensity-modulated radiotherapy.
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Shen X, Spratt DE, Dusetzina SB, Chen RC. Variations in Medical Necessity Determinations Across Commercial Insurance Carriers for Prostate Cancer Procedures. Int J Radiat Oncol Biol Phys 2023; 115:34-38. [PMID: 35918053 DOI: 10.1016/j.ijrobp.2022.07.1839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/20/2022] [Accepted: 07/27/2022] [Indexed: 11/20/2022]
Abstract
PURPOSE Variation in commercial insurance coverage may lead to disparity in access to quality cancer care. We evaluated commercial insurance coverage determinations to assess the degree of variation across a national sample. METHODS AND MATERIALS We identified the predominant carrier of commercial insurance in each state based on the 2020 US Government Accounting Office (GAO-21-34) report on insurance. For each state, publicly available medical policies from January 1, 2021 to January 31, 2021 were analyzed for coverage of 3 widely accepted procedures: hydrogel spacer, fluciclovine- positron emission tomography (PET), and intensity modulated radiation in low volume metastatic prostate cancer. RESULTS We analyzed 83 commercial medical policies across 51 states and District of Columbia. There was widespread variation in coverage policy. Hydrogel spacer was determined medically necessary in 9 states, mixed coverage in 8, not medically necessary in 22, and no available public policy in 12. Use of fluciclovine-PET required a minimum prostate specific antigen level of 2 ng/mL in 9 states, 1 ng/mL in 17, any minimum prostate specific antigen in 7, mixed coverage in 12, and no publicly available policy in 6. Intensity modulated radiation in low volume metastatic prostate cancer was medically necessary in 17 states, not necessary in 7, and not stated in 27. Insurance carriers often used external utilization management companies such as AIM-Healthcare and Evicore Healthcare. These determinations were more restrictive than carriers which did not use utilization management. CONCLUSIONS Commercial medical policies vary widely in medical necessity determinations for novel prostate cancer treatment procedures that are Food and Drug-approved and covered by Medicare. These data suggest a need for more consistent methodology for medical necessity determination to mitigate the current state where patients have unequal access to cancer procedures due to the location of residence and age.
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Affiliation(s)
- Xinglei Shen
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City Kansas.
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals, Seidman Cancer Center, Case Comprehensive Cancer Center, Cleveland Ohio
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt Medical Center, Nashville, Tennessee
| | - Ronald C Chen
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City Kansas
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12
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Calvo FA, Ayestaran A, Serrano J, Cambeiro M, Palma J, Meiriño R, Morcillo MA, Lapuente F, Chiva L, Aguilar B, Azcona D, Pedrero D, Pascau J, Delgado JM, Aristu J, Prezado Y. Practice-oriented solutions integrating intraoperative electron irradiation and personalized proton therapy for recurrent or unresectable cancers: Proof of concept and potential for dual FLASH effect. Front Oncol 2022; 12:1037262. [PMID: 36452493 PMCID: PMC9703091 DOI: 10.3389/fonc.2022.1037262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/26/2022] [Indexed: 11/15/2022] Open
Abstract
Background Oligo-recurrent disease has a consolidated evidence of long-term surviving patients due to the use of intense local cancer therapy. The latter combines real-time surgical exploration/resection with high-energy electron beam single dose of irradiation. This results in a very precise radiation dose deposit, which is an essential element of contemporary multidisciplinary individualized oncology. Methods Patient candidates to proton therapy were evaluated in Multidisciplinary Tumor Board to consider improved treatment options based on the institutional resources and expertise. Proton therapy was delivered by a synchrotron-based pencil beam scanning technology with energy levels from 70.2 to 228.7 MeV, whereas intraoperative electrons were generated in a miniaturized linear accelerator with dose rates ranging from 22 to 36 Gy/min (at Dmax) and energies from 6 to 12 MeV. Results In a period of 24 months, 327 patients were treated with proton therapy: 218 were adults, 97 had recurrent cancer, and 54 required re-irradiation. The specific radiation modalities selected in five cases included an integral strategy to optimize the local disease management by the combination of surgery, intraoperative electron boost, and external pencil beam proton therapy as components of the radiotherapy management. Recurrent cancer was present in four cases (cervix, sarcoma, melanoma, and rectum), and one patient had a primary unresectable locally advanced pancreatic adenocarcinoma. In re-irradiated patients (cervix and rectum), a tentative radical total dose was achieved by integrating beams of electrons (ranging from 10- to 20-Gy single dose) and protons (30 to 54-Gy Relative Biological Effectiveness (RBE), in 10-25 fractions). Conclusions Individual case solution strategies combining intraoperative electron radiation therapy and proton therapy for patients with oligo-recurrent or unresectable localized cancer are feasible. The potential of this combination can be clinically explored with electron and proton FLASH beams.
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Affiliation(s)
- Felipe A Calvo
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Adriana Ayestaran
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Javier Serrano
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Mauricio Cambeiro
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Jacobo Palma
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Rosa Meiriño
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Miguel A Morcillo
- Medical Applications Unit, Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas (CIEMAT), Madrid, Spain
| | - Fernando Lapuente
- Department of Surgery, Clinica Universidad de Navarra, Madrid, Spain
| | - Luis Chiva
- Department of Gynecology and Obstretics, Clinica Universidad de Navarra, Madrid, Spain
| | - Borja Aguilar
- Department of Medical Physics, Clinica Universidad de Navarra, Madrid, Spain
| | - Diego Azcona
- Department of Medical Physics, Clinica Universidad de Navarra, Madrid, Spain
| | - Diego Pedrero
- Department of Medical Physics, Clinica Universidad de Navarra, Madrid, Spain
| | - Javier Pascau
- Department of Bioengineering and Aerospace Engineering, Universidad Carlos III de Madrid, Madrid, Spain
| | - José Miguel Delgado
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Javier Aristu
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Yolanda Prezado
- Translational Research Department. Institut Curie, Université PSL, CNRS UMR, Inserm, Signalisation, Radiobiologie et Cancer, Orsay, France.,Université Paris-Saclay, CNRS UMR, Inserm, Signalisation, Radiobiologie et Cancer, Orsay, France
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13
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Prior authorization in gynecologic oncology: An analysis of clinical impact. Gynecol Oncol 2022; 167:519-522. [PMID: 36244827 DOI: 10.1016/j.ygyno.2022.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/25/2022] [Accepted: 10/01/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Prior authorization was designed to minimize unnecessary care and reduce spending but has been associated with delays in necessary care. Our objective was to estimate the occurrence of prior authorization, and impact on cancer care, in gynecologic oncology. METHODS We performed a retrospective cross-sectional study of patients seen in University of Pennsylvania gynecologic oncology practices (January-March 2021). Using electronic medical records, we measured the incidence of prior authorization during the 3-month period and prior experience of prior authorization for cancer care overall and by type of order (chemotherapy, imaging, surgery, prescription drugs). We assessed the impact of prior authorization occurrence on clinical outcomes (time to service, changes in care). RESULTS Of the 2112 clinic visits of 1406 unique patients, 5% experienced prior authorization during the 3-month study period. An additional 20% faced prior authorization requests earlier in cancer care. Of the 83 prior authorization requests, imaging accounted for the majority (54%) followed by supportive medications (29%) and chemotherapy (17%). After appeal, 79% of cases were approved. For patients whose prior authorizations were approved, there was a mean of 16 days from order placement to care delivery (95% CI 11-20, range 0-98 days). Of the 17 denials, 3 (18%) led to a substantial change in care (i.e., not receiving planned treatment). CONCLUSION 25% of gynecologic oncology patients experienced prior authorization during their cancer care. While 80% of claims were ultimately approved, patients experienced over a 2-week delay in care when prior authorization occurred. Reform is needed to reduce the burden of prior authorization in oncology.
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14
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Nuyts S, Bollen H, Ng SP, Corry J, Eisbruch A, Mendenhall WM, Smee R, Strojan P, Ng WT, Ferlito A. Proton Therapy for Squamous Cell Carcinoma of the Head and Neck: Early Clinical Experience and Current Challenges. Cancers (Basel) 2022; 14:cancers14112587. [PMID: 35681568 PMCID: PMC9179360 DOI: 10.3390/cancers14112587] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/18/2022] [Accepted: 05/20/2022] [Indexed: 11/19/2022] Open
Abstract
Simple Summary Proton therapy is a promising type of radiation therapy used to destroy tumor cells. It has the potential to further improve the outcomes for patients with head and neck cancer since it allows to minimize the radiation dose to vital structures around the tumor, leading to less toxicity. This paper describes the current experience worldwide with proton therapy in head and neck cancer. Abstract Proton therapy (PT) is a promising development in radiation oncology, with the potential to further improve outcomes for patients with squamous cell carcinoma of the head and neck (HNSCC). By utilizing the finite range of protons, healthy tissue can be spared from beam exit doses that would otherwise be irradiated with photon-based treatments. Current evidence on PT for HNSCC is limited to comparative dosimetric analyses and retrospective single-institution series. As a consequence, the recognized indications for the reimbursement of PT remain scarce in most countries. Nevertheless, approximately 100 PT centers are in operation worldwide, and initial experiences for HNSCC are being reported. This review aims to summarize the results of the early clinical experience with PT for HNSCC and the challenges that are currently faced.
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Affiliation(s)
- Sandra Nuyts
- Laboratory of Experimental Radiotherapy, Department of Oncology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium;
- Department of Oncology, Leuven Cancer Institute, Universitair Ziekenhuis Leuven, 3000 Leuven, Belgium
- Correspondence:
| | - Heleen Bollen
- Laboratory of Experimental Radiotherapy, Department of Oncology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium;
- Department of Oncology, Leuven Cancer Institute, Universitair Ziekenhuis Leuven, 3000 Leuven, Belgium
| | - Sweet Ping Ng
- Department of Radiation Oncology, Austin Health, The University of Melbourne, Melbourne, VIC 3000, Australia;
| | - June Corry
- Division of Medicine, Department of Radiation Oncology, St. Vincent’s Hospital, The University of Melbourne, Melbourne, VIC 3000, Australia;
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, USA;
| | - William M Mendenhall
- Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, FL 32209, USA;
| | - Robert Smee
- Department of Radiation Oncology, The Prince of Wales Cancer Centre, Sydney, NSW 2031, Australia;
| | - Primoz Strojan
- Department of Radiation Oncology, Institute of Oncology, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Wai Tong Ng
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China;
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, 35125 Padua, Italy;
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15
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Xia Z, Wang J, Xia J, Wang M, Cheng Z. Inequality in Accessibility of Proton Therapy for Cancers and Its Economic Determinants: A Cross-Sectional Study. Front Oncol 2022; 12:876368. [PMID: 35669433 PMCID: PMC9163414 DOI: 10.3389/fonc.2022.876368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/08/2022] [Indexed: 11/19/2022] Open
Abstract
Background Cancer is a leading cause of death in the world, and the estimated new cancer cases were 19 million and the estimated cancer deaths were around 10 million worldwide in 2020. Proton therapy (PT) is a promising treatment for cancers; however, only few patients with cancer received PT due to limited number of PT centers worldwide, especially in low- and middle-income countries. Methods and Results Cross-sectional country level data were collected from publicly available information. Lorenz curves and Gini coefficient were used to assess the inequality in accessing to PT, and zero-inflated Poisson models were used to investigate the determinants of number of PT facilities in each country. The Gini coefficients were 0.96 for PT centers and 0.96 for PT chambers, which indicated high level of inequality. Total GDP had a significant impact on whether a country had a practical PT center, whereas total GDP and GDP per capita had significant impacts on the number of PT centers. Conclusion Extremely high inequality exists in accessibility of PT centers among all countries in the world. Economic development was the most important factor determining the adoption of PT; thus, with the growth in global economics, more PT centers can be expected in near future.
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Affiliation(s)
- Zhongying Xia
- Department of Oncology of Integrated Traditional Chinese and Western Medicine, China-Japan Friendship Hospital, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Junfeng Wang
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Jiaxin Xia
- College of Pharmacy, Hunan University of Chinese Medicine, Changsha, China
| | - Menglei Wang
- College of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Zhiqiang Cheng
- Department of Oncology of Integrated Traditional Chinese and Western Medicine, China-Japan Friendship Hospital, Beijing, China
- *Correspondence: Zhiqiang Cheng,
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16
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Nogueira LM, Sineshaw HM, Jemal A, Pollack CE, Efstathiou JA, Yabroff KR. Association of Race With Receipt of Proton Beam Therapy for Patients With Newly Diagnosed Cancer in the US, 2004-2018. JAMA Netw Open 2022; 5:e228970. [PMID: 35471569 PMCID: PMC9044116 DOI: 10.1001/jamanetworkopen.2022.8970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Black patients are less likely than White patients to receive guideline-concordant cancer care in the US. Proton beam therapy (PBT) is a potentially superior technology to photon radiotherapy for tumors with complex anatomy, tumors surrounded by sensitive tissues, and childhood cancers. OBJECTIVE To evaluate whether there are racial disparities in the receipt of PBT among Black and White individuals diagnosed with all PBT-eligible cancers in the US. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study evaluated Black and White individuals diagnosed with PBT-eligible cancers between January 1, 2004, and December 31, 2018, in the National Cancer Database, a nationwide hospital-based cancer registry that collects data on radiation treatment, even when it is received outside the reporting facility. American Society of Radiation Oncology model policies were used to classify patients into those for whom PBT is the recommended radiation therapy modality (group 1) and those for whom evidence of PBT efficacy is still under investigation (group 2). Propensity score matching was used to ensure comparability of Black and White patients' clinical characteristics and regional availability of PBT according to the National Academy of Medicine's definition of disparities. Data analysis was performed from October 4, 2021, to February 22, 2022. EXPOSURE Patients' self-identified race was ascertained from medical records. MAIN OUTCOMES AND MEASURES The main outcome was receipt of PBT, with disparities in this therapy's use evaluated with logistic regression analysis. RESULTS Of the 5 225 929 patients who were eligible to receive PBT and included in the study, 13.6% were Black, 86.4% were White, and 54.3% were female. The mean (SD) age at diagnosis was 63.2 (12.4) years. Black patients were less likely to be treated with PBT than their White counterparts (0.3% vs 0.5%; odds ratio [OR], 0.67; 95% CI, 0.64-0.71). Racial disparities were greater for group 1 cancers (0.4% vs 0.8%; OR, 0.49; 95% CI, 0.44-0.55) than group 2 cancers (0.3% vs 0.4%; OR, 0.75; 95% CI, 0.70-0.80). Racial disparities in PBT receipt among group 1 cancers increased over time (annual percent change = 0.09, P < .001) and were greatest in 2018, the most recent year of available data. CONCLUSIONS AND RELEVANCE In this cross-sectional study, Black patients were less likely to receive PBT than their White counterparts, and disparities were greatest for cancers for which PBT was the recommended radiation therapy modality. These findings suggest that efforts other than increasing the number of facilities that provide PBT will be needed to eliminate disparities.
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Affiliation(s)
- Leticia M. Nogueira
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Helmneh M. Sineshaw
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Craig E. Pollack
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health and Johns Hopkins School of Nursing, Baltimore, Maryland
| | | | - K. Robin Yabroff
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
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17
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Nogueira LM, Jemal A, Yabroff KR, Efstathiou JA. Assessment of Proton Beam Therapy Use Among Patients With Newly Diagnosed Cancer in the US, 2004-2018. JAMA Netw Open 2022; 5:e229025. [PMID: 35476066 PMCID: PMC9047654 DOI: 10.1001/jamanetworkopen.2022.9025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Proton beam therapy (PBT) is a potentially superior technology to photon radiotherapy for tumors with complex anatomy, those surrounded by sensitive tissues, and childhood cancers. OBJECTIVE To assess patterns of use of PBT according to the present American Society of Radiation Oncology (ASTRO) clinical indications in the US. DESIGN, SETTING, AND PARTICIPANTS Individuals newly diagnosed with cancer between 2004 and 2018 were selected from the National Cancer Database. Data analysis was performed from October 4, 2021, to February 22, 2022. ASTRO's Model Policies (2017) were used to classify patients into group 1, for which health insurance coverage for PBT treatment is recommended, and group 2, for which coverage is recommended only if additional requirements are met. MAIN OUTCOMES AND MEASURES Use of PBT. RESULTS Of the 5 919 368 patients eligible to receive PBT included in the study, 3 206 902 were female (54.2%), and mean (SD) age at diagnosis was 62.6 (12.3) years. Use of PBT in the US increased from 0.4% in 2004 to 1.2% in 2018 (annual percent change [APC], 8.12%; P < .001) due to increases in group 1 from 0.4% in 2010 to 2.2% in 2018 (APC, 21.97; P < .001) and increases in group 2 from 0.03% in 2014 to 0.1% in 2018 (APC, 30.57; P < .001). From 2010 to 2018, among patients in group 2, PBT targeted to the breast increased from 0.0% to 0.9% (APC, 51.95%), and PBT targeted to the lung increased from 0.1% to 0.7% (APC, 28.06%) (P < .001 for both). Use of PBT targeted to the prostate decreased from 1.4% in 2011 to 0.8% in 2014 (APC, -16.48%; P = .03) then increased to 1.3% in 2018 (APC, 12.45; P < .001). Most patients in group 1 treated with PBT had private insurance coverage in 2018 (1039 [55.4%]); Medicare was the most common insurance type among those in group 2 (1973 [52.5%]). CONCLUSIONS AND RELEVANCE The findings of this study show an increase in the use of PBT in the US between 2004 to 2018; prostate was the only cancer site for which PBT use decreased temporarily between 2011 and 2014, increasing again between 2014 and 2018. These findings may be especially relevant for Medicare radiation oncology coverage policies.
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Affiliation(s)
- Leticia M. Nogueira
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - K. Robin Yabroff
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Jason A. Efstathiou
- Department of Radiation Oncology, Department of Radiation Oncology, Massachusetts General Hospital, Boston
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18
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Oncology Trainee Perceptions of the Prior Authorization Process: A National Survey. Adv Radiat Oncol 2022; 7:100861. [PMID: 35118213 PMCID: PMC8792423 DOI: 10.1016/j.adro.2021.100861] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 11/20/2022] Open
Abstract
Purpose The medical trainee perspective regarding the prior authorization process has not been previously assessed. Here we evaluate the perceptions of radiation and medical oncology trainees regarding the prior authorization process and its effect on their training and patient care. Methods and Materials A 12-question, nonincentivized, electronic national survey of radiation and medical oncology trainees at all Accreditation Council for Graduate Medical Education accredited oncology programs was conducted. Participation, perspectives, and experiences with the prior authorization process were assessed by Likert scale, free response, and multiple response selection. Results Between January and March of 2019, the survey was distributed to 1505 trainees at 76 institutions with responses from 174/616 radiation (28.2%) and 139/889 medical oncology trainees (15.6%). The majority (69.2%) reported participating in the prior authorization process (radiation: 78.2% vs medical: 57.6%; P < .01). Most trainees (71%) reported concern for decline in the quality of patient care due to the prior authorization process. The majority of trainees (77.1%) reported decreased enthusiasm for work and choice of profession, with a higher incidence in medical oncology trainees (83.1% vs 73.7%, P = .04). The most commonly recommended modifications by trainees included that the insurance reviewer be in the same specialty as the ordering provider (87.7%), providers be compensated for participation (82.7%), and turnaround time be more rapid (74.3%). Conclusions These data indicate that trainees in US oncology programs are active participants in the prior authorization process and report that prior authorization approvals negatively influence their medical training and the quality of patient care. Additional efforts to revise the insurance approval process are warranted.
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19
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Tambas M, van der Laan HP, Steenbakkers RJHM, Doyen J, Timmermann B, Orlandi E, Hoyer M, Haustermans K, Georg P, Burnet NG, Gregoire V, Calugaru V, Troost EGC, Hoebers F, Calvo FA, Widder J, Eberle F, van Vulpen M, Maingon P, Skóra T, Weber DC, Bergfeldt K, Kubes J, Langendijk JA. Current practice in proton therapy delivery in adult cancer patients across Europe. Radiother Oncol 2021; 167:7-13. [PMID: 34902370 DOI: 10.1016/j.radonc.2021.12.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/18/2021] [Accepted: 12/05/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Major differences exist among proton therapy (PT) centres regarding PT delivery in adult cancer patient. To obtain insight into current practice in Europe, we performed a survey among European PT centres. MATERIALS AND METHODS We designed electronic questionnaires for eight tumour sites, focusing on four main topics: 1) indications and patient selection methods; 2) reimbursement; 3) on-going or planned studies, 4) annual number of patients treated with PT. RESULTS Of 22 centres, 19 (86%) responded. In total, 4233 adult patients are currently treated across Europe annually, of which 46% consists of patients with central nervous system tumours (CNS), 15% head and neck cancer (HNC), 15% prostate, 9% breast, 5% lung, 5% gastrointestinal, 4% lymphoma, 0.3% gynaecological cancers. CNS are treated in all participating centres (n = 19) using PT, HNC in 16 centres, lymphoma in 10 centres, gastrointestinal in 10 centres, breast in 7 centres, prostate in 6 centres, lung in 6 centres, and gynaecological cancers in 3 centres. Reimbursement is provided by national health care systems for the majority of commonly treated tumour sites. Approximately 74% of centres enrol patients for prospective data registration programs. Phase II-III trials are less frequent, due to reimbursement and funding problems. Reasons for not treating certain tumour types with PT are lack of evidence (30%), reimbursement issues (29%) and/or technical limitations (20%). CONCLUSION Across European PT centres, CNS tumours and HNC are the most frequently treated tumour types. Most centres use indication protocols. Lack of evidence for PT and reimbursement issues are the most reported reasons for not treating specific tumour types with PT.
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Affiliation(s)
- Makbule Tambas
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, The Netherlands.
| | - Hans Paul van der Laan
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, The Netherlands
| | - Roel J H M Steenbakkers
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, The Netherlands
| | - Jerome Doyen
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University of Côte d'Azur, Nice, France
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), Germany; German Cancer Consortium (DKTK), Germany
| | - Ester Orlandi
- Radiation Oncology Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Morten Hoyer
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Neil G Burnet
- Proton Beam Therapy Centre, The Christie NHS Foundation Trust, Manchester, UK
| | | | - Valentin Calugaru
- Institut Curie, Radiation Oncology Department, Paris & Proton Center, Orsay, France
| | - Esther G C Troost
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Frank Hoebers
- Department of Radiation Oncology (MAASTRO Clinic), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, The Netherlands
| | - Felipe A Calvo
- Department of Radiation Oncology, University of Navarra, Madrid, Spain
| | - Joachim Widder
- Department of Radiation Oncology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Austria
| | - Fabian Eberle
- Department of Radiotherapy and Radiooncology, University Hospital Marburg, Marburg Ion-Beam Therapy Center (MIT), University Center for Tumor Diseases Frankfurt and Marburg (UCT), Germany
| | | | - Philippe Maingon
- Sorbonne University, AP-HP. Sorbonne University, Hôpitaux Universitaires La Pitié Salpêtrière, Paris, France
| | - Tomasz Skóra
- Maria Skłodowska-Curie National Research Institute of Oncology, Department of Radiotherapy, Kraków, Poland
| | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Switzerland
| | | | - Jiri Kubes
- Depatment of Oncology, Motol University Hospital and Proton Therapy Center Czech, Prague, Czech Republic
| | - Johannes A Langendijk
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, The Netherlands
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Mah D, Yorke E, Zemanaj E, Han Z, Liu H, George J, Lambiase J, Czmielewski C, Lovelock DM, Rimner A, Shepherd AF. A Planning Comparison of IMRT vs. Pencil Beam Scanning for Deep Inspiration Breath Hold Lung Cancers. Med Dosim 2021; 47:26-31. [PMID: 34426041 DOI: 10.1016/j.meddos.2021.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/09/2021] [Accepted: 07/20/2021] [Indexed: 12/25/2022]
Abstract
Deep inspiration breath hold (DIBH) has dosimetric advantages for lung cancer patients treated with external beam therapy, but is difficult for many patients to perform. Proton therapy permits sparing of the downstream organs at risk (OAR). We compared conventionally fractionated proton (p) and photon(x) plans on both free breathing (FB) and DIBH planning CTs to determine the effect of DIBH with proton therapy. We evaluated 24 plans from 6 lung cancer patients treated with photon DIBH on a prospective protocol. All patients were re-planned using pencil beam scanning (PBS) proton therapy. New plans were generated for FB datasets with both modalities. All plans were renormalized to 60 Gy. We evaluated dosimetric parameters for heart, lung and esophagus. We also compared FBp to DIBHx parameters to quantify how FBp plans compare to DIBHx plans. Significant differences were found for lung metrics V20 and mean lung dose between FB and DIBH plans regardless of treatment modality. Furthermore, lung metrics for FBp were comparable or superior to DIBHx, suggesting that FB protons may be a viable alternative for those patients that cannot perform DIBH with IMRT. The heart dose metrics were significantly different for the 5 out of 6 patients where the PTV overlapped the heart as DIBH moved heart out of the high dose volume. Heart dose metrics were further reduced by proton therapy. DIBH offers similar relative advantages for lung sparing for PBS as it does for IMRT but the magnitude of the DIBH related gains in OAR sparing were smaller for PBS than IMRT. FBp plans offer similar or better lung and heart sparing compared to DIBHx plans. For IMRT patients who have difficulty performing DIBH, FB protons may offer an alternative.
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Affiliation(s)
- Dennis Mah
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA.
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Entela Zemanaj
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA
| | - Zhiqiang Han
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA
| | - Haoyang Liu
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA
| | - Jobin George
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA
| | - Jason Lambiase
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA
| | - Christian Czmielewski
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - D Michael Lovelock
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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21
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Chhabra AM, Choi JI, Hasan S, Press RH, Kabarriti R, Lazarev S, Wolden S, Simone CB. Insurer's Black Box: Inexplicable Barriers to Proton Therapy Access for Young Adults. Int J Radiat Oncol Biol Phys 2021; 110:1538-1539. [PMID: 34273325 DOI: 10.1016/j.ijrobp.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/02/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Arpit M Chhabra
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - Shaakir Hasan
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - Robert H Press
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - Rafi Kabarriti
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Stanislav Lazarev
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
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22
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Mendenhall WM, Brooks ED, Smith S, Morris CG, Bryant CB, Henderson RH, Nichols RC, McIntyre K, Klein SL, Mendenhall NP. Insurance Approval for Definitive Proton Therapy for Prostate Cancer. Int J Part Ther 2021; 8:36-42. [PMID: 35127974 PMCID: PMC8768894 DOI: 10.14338/ijpt-21-00002.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/29/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose To determine factors that influence insurance approval for definitive proton therapy (PT) for prostate cancer. Materials and Methods Between 2014 and 2018, 1592 insured patients with localized prostate cancer were evaluated and recommended to undergo definitive PT; 547 patients (34.4%) had commercial insurance, whereas 1045 patients (65.6%) had Medicare/Medicaid. Of those with Medicare, 164 patients (15.7%) had Medicare alone; 677 (64.8%) had supplemental plans; and 204 (19.5%) had secondary commercial insurance. Insurance that “covered” PT for prostate cancer implied that it was an indication designated in the coverage policy. “Not covered” means that the insurance policy did not list prostate cancer as an indication for PT. Of all 1592 patients, 1263 (79.3%) belonged to plans that covered PT per policy. However, approval for PT was still required via medical review for 619 patients (38.9%), comparative dosimetry for 56 patients (3.5%), peer-to-peer discussion for 234 patients (14.7%), and administrative law judge hearings for 3 patients (<0.1%). Multivariate analyses of factors affecting approval were conducted, including risk group (low/intermediate versus high), insurance type (commercial versus Medicare/Medicaid), whether PT was included as a covered benefit under the plan (covered versus not covered), and time period (2014-16 versus 2017 versus 2018). Results On multivariate analysis, factors affecting PT approval for prostate treatment included coverage of PT per policy (97.1% had approval with insurance that covered PT versus 48.6% whose insurance did not cover PT; P < .001); insurance type (32.5% had approval with commercial insurance versus 97.4% with Medicare; P < .001); and time, with 877/987 patients (88.9%) approved between 2014 and 2016, 255/312 patients (81.7%) approved during 2017, and 255/293 patients (87.0%) approved thereafter (P = .02). Clinical factors, including risk group, had no bearing on insurance approval (P = .44). Conclusion Proton insurance approval for prostate cancer has decreased, is most influenced by the type of insurance a patient belongs to, and is unrelated to clinical factors (risk group) in this study. More work is needed to help navigate appropriate access to care and to assist patients seeking definitive PT for prostate cancer treatment.
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Affiliation(s)
- William M. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Eric D. Brooks
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Stephanie Smith
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Curtis B. Bryant
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Randal H. Henderson
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Romaine C. Nichols
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Kathy McIntyre
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Stuart L. Klein
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
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23
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Lin A, Chang JHC, Grover RS, Hoebers FJP, Parvathaneni U, Patel SH, Thariat J, Thomson DJ, Langendijk JA, Frank SJ. PTCOG Head and Neck Subcommittee Consensus Guidelines on Particle Therapy for the Management of Head and Neck Tumors. Int J Part Ther 2021; 8:84-94. [PMID: 34285938 PMCID: PMC8270078 DOI: 10.14338/ijpt-20-00071.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/30/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose Radiation therapy is a standard modality in the treatment for cancers of the head and neck, but is associated with significant short- and long-term side effects. Proton therapy, with its unique physical characteristics, can deliver less dose to normal tissues, resulting in fewer side effects. Proton therapy is currently being used for the treatment of head and neck cancer, with increasing clinical evidence supporting its use. However, barriers to wider adoption include access, cost, and the need for higher-level evidence. Methods The clinical evidence for the use of proton therapy in the treatment of head and neck cancer are reviewed here, including indications, advantages, and challenges. Results The Particle Therapy Cooperative Group Head and Neck Subcommittee task group provides consensus guidelines for the use of proton therapy for head and neck cancer. Conclusion This report can be used as a guide for clinical use, to understand clinical trials, and to inform future research efforts.
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Affiliation(s)
| | | | - Ryan S Grover
- University of California-San Diego, San Diego, CA, USA
| | - Frank J P Hoebers
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | | | - Juliette Thariat
- Radiation Oncology Department, François Baclesse Center/ARCHADE, Normandy University, Caen, France
| | - David J Thomson
- The Christie NHS Foundation Trust, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Johannes A Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Steven J Frank
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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24
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Smith GL, Shih YCT, Frank SJ. Financial Toxicity in Head and Neck Cancer Patients Treated With Proton Therapy. Int J Part Ther 2021; 8:366-373. [PMID: 34285962 PMCID: PMC8270089 DOI: 10.14338/ijpt-20-00054.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/29/2020] [Indexed: 11/21/2022] Open
Abstract
Cancer-related financial toxicity impacts head and neck cancer patients and survivors. With increasing use of proton therapy as a curative treatment for head and neck cancer, the multifaceted financial and economic implications of proton therapy-dimensions of "financial toxicity"-need to be addressed. Herein, we identify knowledge gaps and potential solutions related to the problem of financial toxicity. To date, while cost-effectiveness analysis has been used to assess the value of proton therapy for head and neck cancer, it may not fully incorporate empiric comparisons of patients' and survivors' lost productivity and disability after treatment. A cost-of-illness framework for evaluation could address this gap, thereby more comprehensively identifying the value of proton therapy and distinctly incorporating a measurable aspect of financial toxicity in evaluation. Overall, financial toxicity burdens remain understudied in head and neck cancer patients from a patient-centered perspective. Systematic, validated, and accurate measurement of financial toxicity in patients receiving proton therapy is needed, especially relative to conventional photon-based strategies. This will enrich the evidence base for optimal selection and rationale for payer coverage of available treatment options for head and neck cancer patients. In the setting of cancer care delivery, a combination of conducting proactive screening for financial toxicity in patients selected for proton therapy, initiating early financial navigation in vulnerable patients, engaging stakeholders, improving oncology provider team cost communication, expanding policies to promote price transparency, and expanding insurance coverage for proton therapy are critical practices to mitigate financial toxicity in head and neck cancer patients.
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Affiliation(s)
- Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ya-Chen Tina Shih
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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25
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Huang D, Frank SJ, Verma V, Thaker NG, Brooks ED, Palmer MB, Harrison RF, Deshmukh AA, Ning MS. Cost-Effectiveness Models of Proton Therapy for Head and Neck: Evaluating Quality and Methods to Date. Int J Part Ther 2021; 8:339-353. [PMID: 34285960 PMCID: PMC8270103 DOI: 10.14338/ijpt-20-00058.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/28/2020] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Proton beam therapy (PBT) is associated with less toxicity relative to conventional photon radiotherapy for head-and-neck cancer (HNC). Upfront delivery costs are greater, but PBT can provide superior long-term value by minimizing treatment-related complications. Cost-effectiveness models (CEMs) estimate the relative value of novel technologies (such as PBT) as compared with the established standard of care. However, the uncertainties of CEMs can limit interpretation and applicability. This review serves to (1) assess the methodology and quality of pertinent CEMs in the existing literature, (2) evaluate their suitability for guiding clinical and economic strategies, and (3) discuss areas for improvement among future analyses. MATERIALS AND METHODS PubMed was queried for CEMs specific to PBT for HNC. General characteristics, modeling information, and methodological approaches were extracted for each identified study. Reporting quality was assessed via the Consolidated Health Economic Evaluation Reporting Standards 24-item checklist, whereas methodologic quality was evaluated via the Philips checklist. The Cooper evidence hierarchy scale was employed to analyze parameter inputs referenced within each model. RESULTS At the time of study, only 4 formal CEMs specific to PBT for HNC had been published (2005, 2013, 2018, 2020). The parameter inputs among these various Markov cohort models generally referenced older literature, excluding many clinically relevant complications and applying numerous hypothetical assumptions for toxicity states, incorporating inputs from theoretical complication-probability models because of limited availability of direct clinical evidence. Case numbers among study cohorts were low, and the structural design of some models inadequately reflected the natural history of HNC. Furthermore, cost inputs were incomplete and referenced historic figures. CONCLUSION Contemporary CEMs are needed to incorporate modern estimates for toxicity risks and costs associated with PBT delivery, to provide a more accurate estimate of value, and to improve their clinical applicability with respect to PBT for HNC.
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Affiliation(s)
- Danmeng Huang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Steven J. Frank
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Eric D. Brooks
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | | | - Ross F. Harrison
- Department of Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ashish A. Deshmukh
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Matthew S. Ning
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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26
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Grzywacz V, Quinn TJ, Wilson T, Reitemeier P, Navin M, Hamstra D, Anderson J, Chinnaiyan P, Stevens C, Kabolizadeh P. Ethical Allocation of Proton Therapy and the Insurance Review Process. Pract Radiat Oncol 2021; 11:e449-e458. [PMID: 33548544 DOI: 10.1016/j.prro.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/18/2021] [Accepted: 01/22/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to delineate a scoring system to maximize the ethical allocation of proton beam therapy (PBT) and determine what factors are associated with receipt of PBT, including the role of specific insurance providers. METHODS AND MATERIALS Our scoring system was developed in collaboration with a multidisciplinary panel of experts. Patients submitted for PBT consideration were assigned a score by committee at a weekly peer-reviewed session at a time when our center was operating at capacity. Univariate analysis and multivariable analysis of initial and final insurance response were performed. RESULTS One hundred ninety-seven patients were prospectively reviewed. Ninety-three percent of patients with Medicaid coverage, 88% of patients with Medicare, and 78% of patients with private insurance were ultimately approved for PBT. Median time to final insurance response was 12 days (interquartile range, 9-18 days) for patients who were ultimately denied PBT coverage. Having primary provider C (odds ratio [OR], 14; 95% confidence interval [CI], 1.20-1.96; P = .033) or third party providers A (OR, 4.22; 95% CI, 1.71-10.9; P = .002) or B (OR, 5.28; 95% CI, 1.56-17.2; P = .006) was significantly associated with final insurance denial for PBT on univariate analysis. Total score (OR, 0.79; 95% CI, 0.67-0.90; P = .002) and having coverage through third party provider A (OR, 24.2; 95% CI, 9.51-68.9; P < .001) were associated with final insurance response on multivariable analysis. CONCLUSIONS Our scoring system was significantly associated with receipt of proton beam therapy. Certain insurance providers are less likely to approve PBT for patients, all else being equal. Such a scoring system could be implemented effectively at other PBT facilities, and additional work is needed in ensuring patients with the most to gain from PBT will be approved by their insurance providers.
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Affiliation(s)
- Vincent Grzywacz
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Thomas J Quinn
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Tracey Wilson
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Paul Reitemeier
- Department of Clinical Ethics, Beaumont Health, Royal Oak, Michigan
| | - Mark Navin
- Department of Philosophy, Oakland University, Rochester, Michigan
| | - Daniel Hamstra
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan; Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Joseph Anderson
- Oakland University William Beaumont School of Medicine, Rochester, Michigan; Department of Medical Oncology, Beaumont Health, Royal Oak, Michigan
| | - Prakash Chinnaiyan
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan; Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Craig Stevens
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan; Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Peyman Kabolizadeh
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan; Oakland University William Beaumont School of Medicine, Rochester, Michigan.
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27
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Chiang JS, Yu NY, Daniels TB, Liu W, Schild SE, Sio TT. Proton beam radiotherapy for patients with early-stage and advanced lung cancer: a narrative review with contemporary clinical recommendations. J Thorac Dis 2021; 13:1270-1285. [PMID: 33717598 PMCID: PMC7947490 DOI: 10.21037/jtd-20-2501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Although lung cancer rates are decreasing nationally, lung cancer remains the leading cause of cancer related death. Despite advancements in treatment and technology, overall survival (OS) for lung cancer remains poor. Proton beam therapy (PBT) is an advanced radiation therapy (RT) modality for treatment of lung cancer with the potential to achieve dose escalation to tumor while sparing critical structures due to higher target conformality. In early and late-stage non-small cell lung cancer (NSCLC), dosimetric studies demonstrated reduced doses to organs at risk (OARs) such as the lung, spinal cord, and heart, and clinical studies report limited toxicities with PBT, including hypofractionated regimens. In limited-stage SCLC, studies showed that regimens chemo RT including PBT were well tolerated, which may help optimize clinical outcomes. Improved toxicity profiles may be beneficial in post-operative radiotherapy, for which initial dosimetric and clinical data are encouraging. Sparing of OARs may also increase the proportion of patients able to complete reirradiation for recurrent disease. However, there are various challenges of using PBT including a higher financial burden on healthcare and limited data supporting its cost-effectiveness. Further studies are needed to identify subgroups that benefit from PBT based on prognostic factors, and to evaluate PBT combined with immunotherapy, in order to elucidate the benefit that PBT may offer future lung cancer patients.
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Affiliation(s)
- Jennifer S Chiang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Thomas B Daniels
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
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28
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Liu SM, Brooks ED, Rubin ML, Grosshans DR, Frank SJ, McAleer MF, McGovern SL, Paulino AC, Woodhouse KD. Referral Patterns and Treatment Delays in Medulloblastoma: A Large Academic Proton Center Experience. Int J Part Ther 2020; 7:1-10. [PMID: 33604411 PMCID: PMC7886269 DOI: 10.14338/ijpt-20-00038.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 08/13/2020] [Indexed: 12/04/2022] Open
Abstract
Purpose Patient travel time can cause treatment delays when providers and families decide to seek proton therapy. We examined whether travel distance or referral pattern (domestic versus international) affects time to radiation therapy and subsequent disease outcomes in patients with medulloblastoma at a large academic proton center. Patients and Methods Children with medulloblastoma treated at MD Anderson (MDA) with a protocol of proton beam therapy (PBT) between January 4, 2007, and June 25, 2014, were included in the analysis. The Wilcoxon rank-sum test was used to study the association between time to start of radiation and distance. Classification- and regression-tree analyses were used to explore binary thresholds for continuous covariates (ie, distance). Failure-free survival was defined as the time interval between end of radiation and failure or death. Results 96 patients were included in the analysis: 17 were international (18%); 19 (20%) were from Houston, Texas; 21 were from other cities inside Texas (21%); and 39 (41%) were from other US states. The median time from surgery to start of radiation was not significantly different for international patients (median = 1.45 months) compared with US patients (median = 1.15 months; P = .13). However, time from surgery to start of radiation was significantly longer for patients residing > 1716 km (> 1066 miles) from MDA (median = 1.31 months) than for patients residing ≤ 1716 km (≤ 1066 miles) from MDA (median = 1.05 months; P = .01). This 1- to 2-week delay (median = 7.8 days) did not affect failure-free survival (hazard ratio = 1.34; P = .43). Conclusion We found that short delays in proton access can exist for patients traveling long distances to proton centers. However, in this study, treatment delays did not affect outcomes. This highlights the appropriateness of PBT in the face of travel coordination. Investment by proton centers in a rigorous intake process is justified to offer timely access to curative PBT.
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Affiliation(s)
- Sean M Liu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eric D Brooks
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - M Laura Rubin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - David R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristina D Woodhouse
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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29
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Jin MC, Shi S, Wu A, Sandhu N, Xiang M, Soltys SG, Hiniker S, Li G, Pollom EL. Impact of proton radiotherapy on treatment timing in pediatric and adult patients with CNS tumors. Neurooncol Pract 2020; 7:626-635. [PMID: 33312677 PMCID: PMC7716142 DOI: 10.1093/nop/npaa034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite putative benefits associated with proton radiotherapy in the setting of CNS tumors, numerous barriers limit treatment accessibility. Given these challenges, we explored the association of proton use with variations in treatment timing. METHODS Pediatric and adult patients with histologically confirmed CNS tumors were identified from the National Cancer Database (2004-2015). Univariable and multivariable regression models were constructed to assess factors impacting radiation timing. Multivariable Cox regression was used to evaluate the effect of treatment delay on survival. RESULTS A total of 76 157 patients received photon or proton radiotherapy. Compared to photons, time to proton administration was longer in multiple pediatric (embryonal, ependymal, nonependymal glial, and other) and adult (ependymal, nonependymal glial, meningeal, other) tumor histologies. On adjusted analysis, proton radiotherapy was associated with longer delays in radiotherapy administration in pediatric embryonal tumors (+3.00 weeks, P = .024) and in all adult tumors (embryonal [+1.36 weeks, P = .018], ependymal [+3.15 weeks, P < .001], germ cell [+2.65 weeks, P = .024], glial [+2.15 weeks, P < .001], meningeal [+5.05 weeks, P < .001], and other [+3.06 weeks, P < .001]). In patients with high-risk tumors receiving protons, delays in adjuvant radiotherapy were independently associated with poorer survival (continuous [weeks], adjusted hazard ratio = 1.09, 95% CI = 1.02-1.16). CONCLUSIONS Proton radiotherapy is associated with later radiation initiation in pediatric and adult patients with CNS tumors. In patients with high-risk CNS malignancies receiving protons, delayed adjuvant radiotherapy is associated with poorer survival. Further studies are needed to understand this discrepancy to maximize the potential of proton radiotherapy for CNS malignancies.
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Affiliation(s)
- Michael C Jin
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Siyu Shi
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Adela Wu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Navjot Sandhu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Michael Xiang
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Susan Hiniker
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Erqi L Pollom
- Palo Alto Veterans Affairs Health Care System, Palo Alto, California
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Tambas M, Steenbakkers RJ, van der Laan HP, Wolters AM, Kierkels RG, Scandurra D, Korevaar EW, Oldehinkel E, van Zon-Meijer TW, Both S, van den Hoek JG, Langendijk JA. First experience with model-based selection of head and neck cancer patients for proton therapy. Radiother Oncol 2020; 151:206-213. [DOI: 10.1016/j.radonc.2020.07.056] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/30/2020] [Accepted: 07/31/2020] [Indexed: 12/11/2022]
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Ning MS, Palmer MB, Shah AK, Chambers LC, Garlock LB, Melson BB, Frank SJ. Three-Year Results of a Prospective Statewide Insurance Coverage Pilot for Proton Therapy: Stakeholder Collaboration Improves Patient Access to Care. JCO Oncol Pract 2020; 16:e966-e976. [PMID: 32302271 PMCID: PMC8462618 DOI: 10.1200/jop.19.00437] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Proton therapy is increasingly prescribed, given its potential to improve outcomes; however, prior authorization remains a barrier to access and is associated with frequent denials and treatment delays. We sought to determine whether appropriate access to proton therapy could ensure timely care without overuse or increased costs. METHODS Our large academic cancer center collaborated with a statewide self-funded employer (n = 186,000 enrollees) on an insurance coverage pilot, incorporating a value-based analysis and ensuring preauthorization for appropriate indications. Coverage was ensured for prospective trials and five evidence-supported anatomic sites. Enrollment initiated in 2016 and continued for 3 years. Primary end points were use, authorization time, and cost of care, with case-matched comparison of total charges at 1 month pretreatment through 6 months posttreatment. RESULTS Thirty-two patients were approved over 3 years, with only 22 actually receiving proton therapy, versus a predicted use by 120 patients (P < .01). Median follow-up was 20.1 months, and average authorization time decreased from 17 days to < 1 day (P < .01), significantly enhancing patient access. During this time, 25 patients who met pilot eligibility were instead treated with photons; and 17 patients with > 6 months of follow-up were case matched by treatment site to 17 patients receiving proton therapy, with no significant differences in sex, age, performance status, stage, histology, indication, prescribed fractions, or chemotherapy. Total medical costs (including radiation therapy [RT] and non-RT charges) for patients treated with PBT were lower than expected (a cost increase initially was expected), with no significant difference in total average charges (P = .82), in the context of overall ancillary care use. CONCLUSION This coverage pilot demonstrated that appropriate access to proton therapy does not necessitate overuse or significantly increase comprehensive medical costs. Objective evidence-based coverage polices ensure appropriate patient selection. Stakeholder collaboration can streamline patient access while reducing administrative burden.
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Affiliation(s)
- Matthew S. Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Laura C. Chambers
- Office of Employee Benefits, The University of Texas System, Austin, TX
| | - Laura B. Garlock
- Office of Employee Benefits, The University of Texas System, Austin, TX
| | - Benjamin B. Melson
- Department of Financial Planning and Analysis, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Steven J. Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX
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Wu A, Jin MC, Meola A, Wong HN, Chang SD. Efficacy and toxicity of particle radiotherapy in WHO grade II and grade III meningiomas: a systematic review. Neurosurg Focus 2020; 46:E12. [PMID: 31153145 DOI: 10.3171/2019.3.focus1967] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 03/25/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAdjuvant radiotherapy has become a common addition to the management of high-grade meningiomas, as immediate treatment with radiation following resection has been associated with significantly improved outcomes. Recent investigations into particle therapy have expanded into the management of high-risk meningiomas. Here, the authors systematically review studies on the efficacy and utility of particle-based radiotherapy in the management of high-grade meningioma.METHODSA literature search was developed by first defining the population, intervention, comparison, outcomes, and study design (PICOS). A search strategy was designed for each of three electronic databases: PubMed, Embase, and Scopus. Data extraction was conducted in accordance with the PRISMA guidelines. Outcomes of interest included local disease control, overall survival, and toxicity, which were compared with historical data on photon-based therapies.RESULTSEleven retrospective studies including 240 patients with atypical (WHO grade II) and anaplastic (WHO grade III) meningioma undergoing particle radiation therapy were identified. Five of the 11 studies included in this systematic review focused specifically on WHO grade II and III meningiomas; the others also included WHO grade I meningioma. Across all of the studies, the median follow-up ranged from 6 to 145 months. Local control rates for high-grade meningiomas ranged from 46.7% to 86% by the last follow-up or at 5 years. Overall survival rates ranged from 0% to 100% with better prognoses for atypical than for malignant meningiomas. Radiation necrosis was the most common adverse effect of treatment, occurring in 3.9% of specified cases.CONCLUSIONSDespite the lack of randomized prospective trials, this review of existing retrospective studies suggests that particle therapy, whether an adjuvant or a stand-alone treatment, confers survival benefit with a relatively low risk for severe treatment-derived toxicity compared to standard photon-based therapy. However, additional controlled studies are needed.
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Affiliation(s)
- Adela Wu
- 1Department of Neurosurgery, Stanford Health Care, Palo Alto
| | - Michael C Jin
- 2Stanford University School of Medicine, Stanford; and
| | - Antonio Meola
- 1Department of Neurosurgery, Stanford Health Care, Palo Alto
| | - Hong-Nei Wong
- 3Lane Medical Library, Stanford Medicine, Palo Alto, California
| | - Steven D Chang
- 1Department of Neurosurgery, Stanford Health Care, Palo Alto
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Brooks ED, Ning MS, Palmer MB, Gunn GB, Frank SJ, Shah AK. Strategic Operational Redesign for Successfully Navigating Prior Authorization Barriers at a Large-Volume Proton Therapy Center. JCO Oncol Pract 2020; 16:e1067-e1077. [PMID: 32639929 DOI: 10.1200/jop.19.00533] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Prior authorization (PA) can be a resource-intensive barrier to oncologic care. To improve patient access and reduce delays at our large, academic proton therapy center, we implemented a novel payor-focused strategy to efficiently navigate the PA process while eliminating physician burden and reducing inappropriate denials. METHODS In 2017, business operations were redesigned to better reflect the insurance process: (1) certified medical dosimetrists (CMDs), with their unique treatment expertise, replaced our historical PA team to function as an effective interface among physicians, patients, and payors; (2) a structured, tiered timeline was implemented to hold payors accountable to PA deadlines; and (3) our PA team provided administrative leadership with requisite insurance knowledge. PA outcomes were compared 6 months before and after the intervention. RESULTS After implementation of this multifaceted strategy, the median time to successful appeal (after initial denial of coverage) decreased from 30 to 18 days (P < .001), and the total number of overturned denials increased by 56%. Because of the efficiency of the CMDs, full-time equivalents on the PA team actually decreased by 44%, translating to a 34% reduction in team personnel expenses. Internal referrals increased by 29%, attributable to optimized communication and diminished administrative burden for providers. New treatment starts also increased, resulting in a 37% larger patient census on treatment. CONCLUSION Incorporating payor-focused strategies can improve patient access in a cost-effective manner while decreasing time and administrative burden associated with the PA process. These operational concepts can be adapted for other oncologic practice settings facing analogous PA-related obstacles.
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Affiliation(s)
- Eric D Brooks
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.,University of Florida Health Proton Therapy Institute, Jacksonville, FL
| | - Matthew S Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX
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Forsthoefel MK, Ballew E, Unger KR, Ahn PH, Rudra S, Pang D, Collins SP, Dritschilo A, Harter W, Paudel N, Collins BT, Lischalk JW. Early Experience of the First Single-Room Gantry Mounted Active Scanning Proton Therapy System at an Integrated Cancer Center. Front Oncol 2020; 10:861. [PMID: 32547953 PMCID: PMC7273355 DOI: 10.3389/fonc.2020.00861] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/30/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction: Review the early experience with a single-room gantry mounted active scanning proton therapy system. Material and Methods: All patients treated with proton beam radiotherapy (PBT) were enrolled in an institutional review board-approved patient registry. Proton beam radiotherapy was delivered with a 250 MeV gantry mounted synchrocyclotron in a single-room integrated facility within the pre-existing cancer center. Demographic data, cancer diagnoses, treatment technique, and geographic patterns were obtained for all patients. Treatment plans were evaluated for mixed modality therapy. Insurance approval data was collected for all patients treated with PBT. Results: A total of 132 patients were treated with PBT between March 2018 and June 2019. The most common oncologic subsites treated included the central nervous system (22%), gastrointestinal tract (20%), and genitourinary tract (20%). The most common histologies treated included prostate adenocarcinoma (19%), non-small cell lung cancer (10%), primary CNS gliomas (8%), and esophageal cancer (8%). Rationale for PBT treatment included limitation of dose to adjacent critical organs at risk (67%), reirradiation (19%), and patient comorbidities (11%). Patients received at least one x-ray fraction delivered as prescribed (36%) or less commonly due to unplanned machine downtime (34%). Concurrent systemic therapy was administered to 57 patients (43%). Twenty-six patients (20%) were initially denied insurance coverage and required peer-to-peers (65%), written appeals (12%), secondary insurance approval (12%), and comparison x-ray to proton plans (8%) for subsequent approval. Proton beam radiotherapy approval required a median of 17 days from insurance submission. Discussion: Incorporation of PBT into our existing cancer center allowed for multidisciplinary oncologic treatment of a diverse population of patients. Insurance coverage for PBT presents as a significant hurdle and improvements are needed to provide more timely access to necessary oncologic care.
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Affiliation(s)
- Matthew K Forsthoefel
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Elizabeth Ballew
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Keith R Unger
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Peter H Ahn
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Sonali Rudra
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Dalong Pang
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Anatoly Dritschilo
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - William Harter
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Nitika Paudel
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Brian T Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Jonathan W Lischalk
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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Jin MC, Harris JP, Sabolch AN, Gensheimer M, Le QT, Beadle BM, Pollom EL. Proton radiotherapy and treatment delay in head and neck squamous cell carcinoma. Laryngoscope 2019; 130:E598-E604. [PMID: 31837165 DOI: 10.1002/lary.28458] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/12/2019] [Accepted: 11/16/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE For patients with head and neck squamous cell carcinoma (HNSCC), delays in the initiation of radiotherapy (RT) have been closely associated with worse outcomes. We sought to investigate whether RT modality (proton vs. photon) is associated with differences in the time to initiation of RT. METHODS The National Cancer Database was queried for patients diagnosed with nonmetastatic HNSCC between 2004 and 2015 who received either proton or photon RT as part of their initial treatment. Wilcoxon rank-sum and chi-square tests were used to compare continuous and categorical variables, respectively. Multivariable logistic regression was used to determine the association between use of proton RT and delayed RT initiation. RESULTS A total of 175,088 patients with HNSCC receiving either photon or proton RT were identified. Patients receiving proton RT were more likely to be white, reside in higher income areas, and have private insurance. Proton RT was associated with delayed RT initiation compared to photon RT (median 59 days vs. 45, P < 0.001). Receipt of proton therapy was independently associated with RT initiation beyond 6 weeks after diagnosis (adjusted OR [aOR, definitive RT] = 1.69; 95% confidence interval [CI] 1.26-2.30) or surgery (aOR [adjuvant RT] = 4.08; 95% CI 2.64-6.62). In the context of adjuvant proton RT, increases in treatment delay were associated with worse overall survival (weeks, adjusted hazard ratio = 1.099, 95% CI 1.011-1.194). CONCLUSION Use of proton therapy is associated with delayed RT in both the definitive and adjuvant settings for patients with HNSCC and could be associated with poorer outcomes. LEVEL OF EVIDENCE 2b Laryngoscope, 122:0000-0000, 2019 Laryngoscope, 130:E598-E604, 2020.
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Affiliation(s)
- Michael C Jin
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford
| | - Jeremy P Harris
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford.,Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Aaron N Sabolch
- The Center for Health Research and the Department of Radiation Oncology, Kaiser Permanente, Portland, Oregon, U.S.A
| | - Michael Gensheimer
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford
| | - Quynh-Thu Le
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford
| | - Beth M Beadle
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford.,Palo Alto Veterans Affairs Health Care System, Palo Alto, California
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Yu NY, Sio TT, Mohindra P, Regine WF, Miller RC, Mahajan A, Keole SR. The Insurance Approval Process for Proton Beam Therapy Must Change: Prior Authorization Is Crippling Access to Appropriate Health Care. Int J Radiat Oncol Biol Phys 2019; 104:737-739. [PMID: 31204659 DOI: 10.1016/j.ijrobp.2019.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 04/10/2019] [Accepted: 04/13/2019] [Indexed: 01/18/2023]
Affiliation(s)
- Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Pranshu Mohindra
- Department of Radiation Oncology and Maryland Proton Treatment Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - William F Regine
- Department of Radiation Oncology and Maryland Proton Treatment Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Robert C Miller
- Department of Radiation Oncology and Maryland Proton Treatment Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona.
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Lawell MP, Indelicato DJ, Paulino AC, Hartsell W, Laack NN, Ermoian RP, Perentesis JP, Vatner R, Perkins S, Mangona VS, Hill-Kayser CE, Wolden SL, Kwok Y, Chang JHC, Wilkinson JB, MacEwan I, Chang AL, Eaton BR, Ladra MM, Gallotto SL, Weyman EA, Bajaj BVM, Baliga S, Yeap BY, Berrington de Gonzalez A, Yock TI. An open invitation to join the Pediatric Proton/Photon Consortium Registry to standardize data collection in pediatric radiation oncology. Br J Radiol 2019; 93:20190673. [PMID: 31600082 DOI: 10.1259/bjr.20190673] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE The Pediatric Proton/Photon Consortium Registry (PPCR) is a comprehensive data registry composed of pediatric patients treated with radiation. It was established to expedite outcomes-based research. The attributes which allow the PPCR to be a successful collaboration are reviewed. METHODS AND MATERIALS Current eligibility criteria are radiotherapy patients < 22 years treated at one of the 15 US participating institutions. Detailed health and treatment data are collected about the disease presentation and treatment exposures, and annually thereafter, in REDCap (Research Electronic Data Capture). DICOM (Digital Imaging and Communications in Medicine) imaging and radiation plans are collected through MIM/MIMcloud. An optional patient-reported quality-of-life (PedsQL) study is administered at 10 sites. RESULTS Accrual started October 2012 with 2,775 participants enrolled as of 25 July 2019. Most patients, 62.0%, were treated for central nervous system (CNS) tumors, the most common of which are medulloblastoma (n = 349), ependymoma (n = 309), and glial/astrocytoma tumors (n = 279). The most common non-CNS diagnoses are rhabdomyosarcoma (n = 284), Ewing's sarcoma (n = 153), and neuroblastoma (n = 130). While the majority of participants are US residents, 18.7% come from 36 other countries. Over 685 patients participate in the PedsQL study. CONCLUSIONS The PPCR is a valuable research platform capable of answering countless research questions that will ultimately improve patient care. Centers outside of the USA are invited to participate directly or may engage with the PPCR to align data collection strategies to facilitate large-scale international research. ADVANCES IN KNOWLEDGE For investigators looking to carry out research in a large pediatric oncology cohort or interested in registry work, this paper provides an updated overview of the PPCR.
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Affiliation(s)
- Miranda P Lawell
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida, Gainesville, United States
| | - Arnold C Paulino
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, United States
| | - William Hartsell
- Department of Radiation Oncology, Northwestern Medicine Chicago Proton Center, Warrenville, United States
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, United States
| | - Ralph P Ermoian
- Department of Radiation Oncology, University of Washington, Seattle, United States
| | - John P Perentesis
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
| | - Ralph Vatner
- Department of Radiation Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
| | - Stephanie Perkins
- Department of Radiation Oncology, Washington University, St. Louis, United States
| | - Victor S Mangona
- Department of Radiation Oncology, Texas Center for Proton Therapy, Irving, United States
| | | | - Suzanne L Wolden
- Department of Radiation Oncology, ProCure Proton Therapy Center, New Jersey, United States
| | - Young Kwok
- Department of Radiation Oncology, University of Maryland, College park, United States
| | - John Han-Chih Chang
- Department of Radiation Oncology, Oklahoma Proton Therapy Center, Oklahoma, United States
| | - J Ben Wilkinson
- Department of Radiation Oncology, Provision Healthcare, Knoxville, United States
| | - Iain MacEwan
- Department of Radiation Oncology, California Protons Cancer Therapy Center, San Diego, United States
| | - Andrew L Chang
- Department of Radiation Oncology, California Protons Cancer Therapy Center, San Diego, United States
| | - Bree R Eaton
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, United States
| | - Matthew M Ladra
- Department of Pediatric Radiation Oncology, John Hopkins Kimmel Cancer Center at Sibley Memorial Hospital, Washington, United States
| | - Sara L Gallotto
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Elizabeth A Weyman
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Benjamin V M Bajaj
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Sujith Baliga
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Beow Y Yeap
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Amy Berrington de Gonzalez
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer InstituteNational Institutes of Health, Bethesda, United States
| | - Torunn I Yock
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
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Mendenhall WM, Smith S, Morris CG, Bradley JA, Mailhot Vega RB, McIntyre K, Klein SL, Mendenhall NP. Insurance Coverage for Adjuvant Proton Therapy in the Definitive Treatment of Breast Cancer. Int J Part Ther 2019; 6:26-30. [PMID: 31998818 DOI: 10.14338/ijpt-19-00070.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/09/2019] [Indexed: 11/21/2022] Open
Abstract
Purpose To determine factors that influence insurance approval for breast cancer patients for whom adjuvant proton therapy (PT) is recommended. Patients and Methods We sought to identify factors associated with PT approval among 131 insured patients seen in consultation between 2014 and 2018 and recommended adjuvant PT. Insurance status included: commercial, 76 patients (58%); Medicare, 41 (31%); and Medicaid, 14 (11%). Ninety-six patients (73%) had policies that "covered" PT. Insurance "coverage" for PT was not associated with final approval nor was lack of "coverage" associated with denial despite additional steps of medical review, peer-to-peer discussion, patient appeal, and judicial review.In seeking approval, the following steps were required: medical review, 73 patients (56%); comparative dosimetry, 34 patients (26%); peer-to-peer discussion, 20 patients (15%); and administrative law judge, 1 patient (1%). A multivariate analysis of predictors for final insurance approval was conducted including the following covariates: T stage (Tis-T2 vs T3-T4); N stage (N0 vs N1-N3); laterality (left or bilateral vs right); insurance type (commercial vs Medicare/Medicaid) combined with potential insurance coverage (covered vs not covered); time period (2014-2016 vs 2017-2018); and age (<57 years vs 57 and older). Results Insurance approval was obtained for 93/96 patients (97%) with insurance that covered PT versus 23/35 patients (66%) whose insurance did not cover PT. Insurance approval stratified by insurance type and coverage was: commercial-covered, 52/52 patients (100%); Medicare or Medicaid-covered, 41/44 (93%); commercial-not covered, 16/22 (73%); and Medicare or Medicaid-not covered, 7/13 (54%).On multivariate analysis, factors impacting approval revealed T stage, p=0.3127; N stage, p=0.8524; laterality, p=0.1829; insurance type combined with potential coverage, p<0.0001; time period, p=0.2731; and age, p=0.6678. Conclusion The only parameter that significantly influenced approval for treatment with PT was insurance type combined with potential coverage with ultimate approval rates ranging from 54% to 100%.
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Affiliation(s)
| | - Stephanie Smith
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | | | - Julie A Bradley
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | | | - Kathy McIntyre
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Stuart L Klein
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Nancy P Mendenhall
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
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Brooks ED, Ning MS, Verma V, Zhu XR, Chang JY. Proton therapy for non-small cell lung cancer: the road ahead. Transl Lung Cancer Res 2019; 8:S202-S212. [PMID: 31673525 PMCID: PMC6795573 DOI: 10.21037/tlcr.2019.07.08] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 07/17/2019] [Indexed: 12/14/2022]
Abstract
Proton therapy is an evolving radiotherapy modality with indication for numerous cancer types. With the benefits of reducing dose and sparing normal tissue, protons offer a clear physical and dosimetric advantage over photon radiotherapy for many patients. However, its impact on one type of disease, non-small cell lung cancer (NSCLC), is still not fully understood. Our review aims to highlight the data for using proton therapy in NSCLC, with a focus on the clinical data-or lack thereof-supporting proton treatment for early and advanced stage disease. In evaluating these data, we consider how future directions and advances in proton technology give rise for hope in defining a role for protons in improving NSCLC outcomes. We close with considerations for next steps and the challenges ahead in using proton therapy for this unique patient population.
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Affiliation(s)
- Eric D. Brooks
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew S. Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - X. Ronald Zhu
- Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joe Y. Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Verma V, Ludmir EB, Mesko SM, Brooks ED, Augustyn A, Milano MT, Lin SH, Chang JY, Welsh JW. Commercial Insurance Coverage of Advanced Radiation Therapy Techniques Compared With American Society for Radiation Oncology Model Policies. Pract Radiat Oncol 2019; 10:324-329. [PMID: 31446147 DOI: 10.1016/j.prro.2019.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 08/08/2019] [Accepted: 08/15/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE This study aimed to compare and contrast the American Society for Radiation Oncology (ASTRO) model policies (MPs) for intensity modulated radiation therapy (IMRT), stereotactic radiosurgery (SRS), stereotactic ablative radiation therapy (SABR), and proton beam therapy (PBT) with the coverage policies constructed by 5 of the largest publicly available commercial insurers throughout the United States (ie, Aetna, Anthem, Cigna, Humana, and United Healthcare). METHODS AND MATERIALS Appropriate indications for IMRT, SRS, SABR, and PBT by disease site (and particular clinical setting thereof) were extracted from the most recently published ASTRO MPs and published coverage policies (2019 editions) of the 5 carriers. After tabulation, concordance between ASTRO MPs and insurance policies were calculated for each modality. RESULTS All 5 insurer policies supported IMRT for neoplasms of the central nervous system, head/neck, hepatopancreaticobiliary, anal, and prostate cancers. The least covered diseases were retroperitoneal tumors (n = 0 carriers) and bladder cancer (n = 1). For SRS, all carriers covered benign brain tumors, brain metastases, arteriovenous malformations, and trigeminal neuralgia. None of the insurance carriers covered SRS for medically refractory epilepsy. For SABR, primary liver, lung, and low- or intermediate-risk prostate cancer were covered by all insurers, and none allowed SABR for primary biliary neoplasms. Only one insurance carrier each covered SABR for primary/metastatic adrenal disease and primary renal cancer. All carriers approved PBT for ocular melanoma, skull base tumors, and pediatric malignancies. The ASTRO MPs listed 4 PBT scenarios (ie, spinal disease, retroperitoneal sarcoma, head/neck neoplasms, and patients with genetic radiosensitivity syndromes) not covered by any insurer. Concordance between insurance carriers and ASTRO MPs was 67.8% for IMRT, 72.0% for SRS, 58.4% for SABR, and 41.8% for PBT (P = .005). CONCLUSIONS Coverage guidelines for IMRT, SRS, SABR, and PBT vary across 5 major insurance providers and may be substantially discordant compared with ASTRO coverage guidelines. There remain several specific areas where ongoing and future dialogues between ASTRO members, payers, and policymakers remain essential.
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Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, Pennsylvania.
| | - Ethan B Ludmir
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shane M Mesko
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eric D Brooks
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alexander Augustyn
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Steven H Lin
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joe Y Chang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - James W Welsh
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
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Gjyshi O, Liao Z. Proton therapy for locally advanced non-small cell lung cancer. Br J Radiol 2019; 93:20190378. [PMID: 31430188 DOI: 10.1259/bjr.20190378] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Radiation therapy is an essential component of treatment for locally advanced non-small cell lung cancer (NSCLC) but can be technically challenging because of the proximity of lung tumors to nearby critical organs or structures. The most effective strategy for reducing radiation-induced toxicity is to reduce unnecessary exposure of normal tissues by using advanced technology; examples from photon (X-ray) therapy have included three-dimensional conformal radiation therapy versus its predecessor, two-dimensional radiation therapy, and intensity-modulated photon radiation therapy versus its predecessor, three-dimensional conformal therapy. Using particle-beam therapy rather than photons offers the potential for further advantages because of the unique depth-dose characteristics of the particles, which can be exploited to allow still higher dose escalation to tumors with greater sparing of normal tissues, with the ultimate goal of improving local tumor control and survival while preserving quality of life by reducing treatment-related toxicity. However, the costs associated with particle therapy with protons are considerably higher than the current state of the art in photon technology, and evidence of clinical benefit from protons is increasingly being demanded to justify the higher financial burden on the healthcare system. Some such evidence is available from preclinical studies, from retrospective, single-institution clinical series, from analyses of national databases, and from single-arm prospective studies in addition to several ongoing randomized comparative trials. This review summarizes the rationale for and challenges of using proton therapy to treat thoracic cancers, reviews the current clinical experience, and suggests topics for future research.
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Affiliation(s)
- Olsi Gjyshi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center Houston, Texas, USA
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center Houston, Texas, USA
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Swisher-McClure S, Bekelman JE. It's the Team, Not the Beam. Int J Radiat Oncol Biol Phys 2019; 104:734-736. [PMID: 31204658 DOI: 10.1016/j.ijrobp.2019.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 02/01/2019] [Accepted: 02/06/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Samuel Swisher-McClure
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Justin E Bekelman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
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Remick JS, Bentzen SM, Simone CB, Nichols E, Suntharalingam M, Regine WF. Downstream Effect of a Proton Treatment Center on an Academic Medical Center. Int J Radiat Oncol Biol Phys 2019; 104:756-764. [PMID: 30885776 DOI: 10.1016/j.ijrobp.2019.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 02/22/2019] [Accepted: 03/11/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE To quantify the effects of opening a proton center (PC) on an academic medical center (AMC)/radiation oncology department. METHODS AND MATERIALS Radiation treatment volume and relative value units from fiscal year 2015 (FY15) to FY17 were retrospectively analyzed at the AMC and 2 community-based centers. To quantify new patient referrals to the AMC, we reviewed the electronic medical record for all patients seen at the PC since consults were initiated in November 2015 (n = 1173). Patients were excluded if the date of entry into the AMC electronic medical record predated their PC consultation. Hospital resource use and professional and technical charges were obtained for these patients. Academic growth, philanthropy, and resident education were evaluated based on grant submissions, clinical trial enrollment, philanthropy, and pediatric case exposure, respectively, from PC opening through FY17. RESULTS From FY15 to FY17, radiation fractions at the AMC and the 2 community sites decreased by 14% (95% confidence interval [CI], 12%-16%, P < .001) and increased by 19% (95% CI, 16%-23%, P < .001) and 2% (95% CI, -1.1 to 4.3%, P = NS), respectively; the number of new starts decreased by 3% (95% CI, -13% to 7%, P = NS) and 2% (95% CI, -20% to 16%, P = NS) and increased by 13% (95% CI -2% to 27%, P = NS), respectively. At the AMC, technical and professional relative value units decreased by 5% and 14%, respectively. The PC made 561 external referrals to the AMC, which resulted in $2.38 million technical and $2.13 million professional charges at the AMC. Fifteen grant submissions ($12.83 million) resulted in 6 awards ($3.26 million). Twenty-two clinical trials involving proton therapy were opened, on which a total of 5% (n = 54) of patients enrolled during calendar years 2017 and 2018. The PC was involved in gift donations of $1.6 million. There was a nonsignificant 37% increase in number of pediatric cases. CONCLUSIONS Despite a slight decline in AMC photon patient volumes and relative value units, a positive downstream effect was associated with the addition of a PC, which benefited the AMC.
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Affiliation(s)
- Jill S Remick
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland
| | - Søren M Bentzen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Elizabeth Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mohan Suntharalingam
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland.
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