Promising Protons: A New Provision For Prostate Cancer Treatment Perils

When I first saw the TV spot touting proton therapy for prostate cancer, I was totally turned off. The ad shows seven aging men cheering in the stands at a football game while wearing the letters PROTONS painted in orange on their bare chests. A voiceover proclaims, "Proton therapy—the only cancer treatment with a fan club."

A sequel features several local luminaries in hokey hospital gowns urging men to get tested for prostate cancer. University of Tennessee Chancellor Jimmy Cheek sounds like a shill as he exhorts, "Because early detection screenings save lives, real men wear gowns."

The ads are "Brought to you by Provision Proton Therapy—Coming in 2014." And just who is that? It's a new entity located just off Middlebrook Pike in which the mega-millionaire Terry Douglas has invested $120 million as an encore to his success as a founder of CTI Molecular Imaging, which was sold to the German giant Siemens in 2005.

The Provision Proton ads don't mention that the respected U.S. Preventive Services Task Force has advised men to not get the blood test known as PSA that's most widely used for prostate cancer screening. The Task Force's recommendation, which is endorsed by the federal Centers for Disease Control and Prevention (CDC) concludes that: "Although the long-term effect of PSA screening on prostate cancer-specific mortality remains uncertain, existing studies adequately demonstrate that the reduction in prostrate cancer mortalities after 10 to 14 years is at most very small... In contrast to the harms associated with the diagnosis and treatment of screen-detected cancer are common, occur early, often persist, and include a small but real risk for premature death." In other words, the cure may be worse than the disease.

Nor do the ads mention that proton therapy, as presently offered at only four locations in the U.S., is typically twice as costly as the types of radiation therapy in much wider use for treating prostate cancer. As a result, many health insurers, including Blue Cross Blue Shield in Tennessee, won't cover it (although proton therapy is recognized to be preferable and is covered for a number of much less frequently occurring cancers, including head and neck tumors in adults and almost all types in children).

Yet I've got to say that a visit to Provision Proton's imposing facility went a long way toward dispelling my cynical preconception that its marketing is aimed at herding hordes of older men through pricey treatment in order to turn a profit on its huge investment.

For one thing, I learned that the center is organized as a not-for-profit. While the massive 220-ton cyclotron, 90-ton gantry, and particle beams imported from Belgium that will drive it are expected to deliver enough treatments to cover its overhead, this initial installation is really just a stepping stone.

The end game is production of a much smaller, lighter, lower-cost "next generation" system that's being developed by a for-profit sister company, ProNova Solutions, for worldwide sales within a year or two. A prototype of the ProNova SC360, as it's called, has already been installed at the Provision Center where its performance can be benchmarked against the proven Belgian system, whose manufacturer, IBA, presently has a near monopoly on the market for proton therapy equipment.

Bill Hansen, who had been IBA's director of global marketing, joined Provision earlier this year as vice president for strategic development. He anticipates that the SC360, which is being produced at a separate facility in Alcoa, will gain approval from the federal Food and Drug Administration by early 2015, and he foresees a market for 1,000 installations in the U.S. and 2,000 worldwide.

I also came away impressed that, to the extent prostate cancer needs to be treated, proton therapy has advantages over the two prevalent types of treatment in use presently—namely, standard radiation or surgical removal of the prostate. The principal benefit is that protons can be targeted much more precisely at a tumor than X-rays and thus minimize the risk of side effects from damage to adjacent healthy tissue or complications from surgery. In the case of prostate cancer, which is by far the most widely occurring type of malignancy in men, these side effects include impotence, incontinence, and damage to the bowels, which are also in close proximity to the prostate.

Hansen also insists that the SC360 will overcome the one disadvantage of proton therapy—namely, its higher cost. The technology for getting its cost down goes way over my head. But Hansen puts his emphasis on two facets of it: 1.) The use of superconducting magnets to beam protons to their targets more efficiently; and 2.) a process known as hypofractionation that increases the dose per treatment session and reduces the number of sessions required.

At present, Hansen says, the standard for proton therapy is about 40 treatment sessions spread over eight weeks at a cost of about $1,000 per treatment. With "pencil beam scanning" and hypofractionation, the number of treatments and the cost can be cut in half, he claims. That would bring the cost of proton therapy in line with standard radiation treatment costs of about $20,000. "So we're proposing to the insurance companies that we will do it at the same price and still give patients the benefits of proton therapy," Hansen says.

He foresees these benefits being extended to the treatment of many other types of cancer that are presently treated in other ways, including the three deadliest: lung, colon, and breast cancer.

One question that remains is whether prostate cancer should be treated at all. While it's the most commonly occurring, it's also commonly one of the slowest-growing types of cancer. So when it's diagnosed in older men, an adage in the medical community is that they are much more likely to die with it than die of it. Ergo, the admonition, endorsed by the CDC. But if the risk of side effects were proven minimal, then screening and resultant treatment would have to be viewed more favorably.