[gdpawel]

Physicians tend to settle on the smallest amount of tumor tissue possible, often with a fine needle aspirate that collects just a few cells, for biopsy analysis. Larger bore needles (tru-cut) are needed to perform core biopsies or even remove entire lymph nodes, so that they can collect enough "live" tissue to more reliably determine the histologic and molecular features of a cancer. Imaging technologies cannot substitute for the biologist's thorough examination of the features of a cancer cell.

I am not a proponent of "diffuse" radiation therapy. So the high energy proton beam, which is a "focused" radiation technique, is appealing to me, although at a more expensive approach. Accuracy is the key to effective radiation treatment with minimal collateral damage (the same as for chemotherapy treatment).

But, is the proliferation of proton beam outpacing evidence? Proton therapy still requires manual beam attenuation and there is no integrated feedback. I understand that better technology is being developed to eliminate the need for manual beam attenuation and promoting 3D control, but it's five years or so away.

Brian Baker is an executive of Regents Health Resources, which helps hospitals and physicians develop and manage their medical imaging services. He was interviewed for Community Oncology. He said that "if you look at cancer trends worldwide and then estimate proton beam therapy use based on today's indications, the world market opportunity is only around a total of 250 units. That need will likely change as proton beam adopts some of the automation technologies."

Baker says that "a four-gantry proton therapy center costs as much as a small hospital ($125 million). The cost of proton beam equipment alone is well over $50 million." Proton beam is reimbursed at $25,000 (on average) per patient. And Medicare increased reimbursement. It's also worth noting that the physics behind a 900-ton synchrocyclotron getting those protons close to the speed of light may need as much as a city block of real estate.

Baker agreed that $125 million for a proton beam unit is a big pill to swallow for something whose capabilities are still being discovered. However, he pointed out that a patient with cancer in the spine may mean the difference between surviving as a quadriplegic, having received radiation therapy, and surviving to live a normal life, having received proton beam therapy.

With the high cost of all this technology and the return on investment considerations, how does the private practitioner compete? His point is to share, not only the risk, but the potential opportunity in the technology.

He says he is "seeing more and more requests for partnerships and joint ventures, which can work very well if people are realistic about their expectations and goals. Partnerships can be structured in many different ways depending on the practice's needs and the legal considerations."

"Of course, the challenge is how to take advantage of the new technology without interrupting patient and revenue streams. Unfortunately, there really is no easy or inexpensive answer for this yet. If your technology is too old to accept an upgrade, the only option that allows for an uninterrupted work flow is to build a new facility."

"Granted, that's expensive and complex," he says, "but it allows the new technology to be integrated, and it positions the practice for the future, while delivering better service to patients."

However, a report from the Agency for Healthare Research and Quality (AHRQ) found no evidence to support claims that cancer patients undergoing pricey proton beam radiation therapy (PRT) achieve outcomes or experience fewer side effects than patients receiving traditional photon radiation.