Hospitals throughout the United States are in a medical arms race, competing for the biggest, newest and "best" technology the health care industry can offer.
And Oklahoma City's health industry is running right alongside the rest of the nation.
By the end of 2013, Oklahoma City will have two cancer centers offering proton therapy, an expensive and somewhat controversial method of treating cancer.
“The unfortunate thing about proton therapy is that it has divided the radiation oncology community into the haves and the have-nots,” said Dr. Sameer Keole, medical director at ProCure Proton Therapy Center in Oklahoma City.
Health care experts agree that the debate around proton therapy points to larger issues of cost that must be solved for the U.S. to have a better and more effective health care system.
Nationwide, there are only about 10 proton therapy centers in operation and another eight centers in development, according to the National Association for Proton Therapy.
Proton beam radiation therapy uses streams of protons, tiny particles with a positive charge, to kill tumor cells, according to the National Cancer Institute.
Proton therapy is thought to be more precise than X-ray radiation, according to the institute.
When a cancer patient is treated with X-rays, the tumor is killed, but so is the healthy tissue around it. Protons are thought to deliver energy that kills a tumor in a more defined path. This theoretically reduces the amount of radiation damage to healthy tissue near the tumor, according to the cancer institute.
Some experts argue that there's not enough evidence to say that proton therapy is any better than conventional cancer therapies in treating common cancers, such as prostate cancer.
More trials sought
The National Cancer Institute has cautioned that, before proton therapy is widely used, more clinical trials are needed to validate where proton therapy is best used.
There are some scenarios, though, where proton therapy has proved better for patients — for example, children with tumors of the eye or at the base of the skull, said Dr. Anthony Zietman, a professor of radiation oncology at Harvard Medical School.
According to research presented this past week at the American Society for Radiation Oncology annual conference, patients undergoing treatment for prostate cancer using proton beam therapy reported a higher quality of life in early follow-up when compared to patients receiving other radiation therapies.
But this wasn't a randomized trial, often referred to as the gold standard in research, and it is being overspun, Zietman said.
What the research suggests is what most research related to proton therapy has suggested — proton therapy likely provides the same, or similar, benefits than other traditional, less expensive forms of radiation, Zietman said.
“No one is saying proton beam is bad treatment — proton beam is good,” Zietman said. “The question is — does it offer value? And this is where Sameer Keole is right — If protons were cheaper, we wouldn't be having this discussion.”
Keole, who has been at ProCure since 2009, talks to groups throughout the U.S. that want to install proton therapy centers.
“I say, ‘Look, if you want to do this for money, I think you're doing it for the wrong reasons. Hopefully it will work out, and it will be at least a break-even proposition, but you have to do it because you believe in proton therapy,'” Keole said.
It's estimated that Medicare reimbursements are between two and three times more for proton therapy. Generally speaking, proton therapy can cost upward of $70,000. More traditional radiation therapy costs about $40,000.
Facilities can get paid $350 for every treatment they do of intensity-modulated radiation therapy, an advanced technology that manipulates beams of radiation to conform to the shape of a tumor, according to the Mayo Clinic.
For proton therapy, that number can range sometimes from $800 to $900 per treatment.
But Keole said the money is not what motivates him. It's the patient outcomes.
Before coming to ProCure, Keole was at the University of Florida Proton Therapy Institute in Jacksonville, Fla.
Initially, Keole didn't believe that proton therapy would be that much better than other types of radiation.
To test that theory, he and his colleagues looked at the outcomes of about 50 patients who were being treated for prostate cancer.
“Do you know how many times a really good (intensity-modulated radiation therapy plan) was better than a proton plan? Zero,” Keole said.
Keole was sold on the anecdotes from these patients. The prostate cancer patients treated with proton therapy were playing golf and leading healthy and active lives and not experiencing side effects such as fatigue, he said.
“Proton therapy is not a fad,” said Keole, who will soon serve as lead proton physician at the Mayo Clinic's Arizona proton center. “It is steeped in science, it makes sense clinically, and let's be honest — if protons cost the same amount of money to install as a regular radiation machine, we would swap all these machines out tomorrow.”
It costs millions of dollars to install and sustain a proton therapy center. For example, ProCure Proton Therapy Center, 5901 W Memorial Road, cost $120 million to build and open.
The Oklahoma City facility was ProCure's first of three centers that are in operation. ProCure also has opened centers in Illinois and New Jersey.
Inside ProCure, there's a 220-ton cyclotron, the core piece of equipment used in proton therapy.
Oklahoma's second cancer center to offer proton therapy will have a different type of equipment that takes up significantly less space and comes at a smaller cost.
Probably by December, the Peggy and Charles Stephenson Cancer Center at the University of Oklahoma will have the Mevion S250 Proton Therapy System.
The system is more compact than ProCure's cyclotron and is estimated to cost between $20 million and $40 million.
Dr. Terence Herman is one of the doctors who will use the machine to treat patients.
Herman, the chairman of radiation oncology at the OU Health Sciences Center, describes himself as a “careful investigator.” He's interested in the biology of proton therapy, but isn't sure what the benefits of the machine will be.
Proton therapy has its advantages, but exactly what those are has not been worked out, he said.
“This place is amazing, and I was just here at the right time,” Herman said. “It is a very wonderful facility. The proton beam may very well add to that. It's going to exist — we bought it. But we're going to study it. That's the thrust of what we're doing, treatment, but research, not just doing the treatment to pay off a terribly large debt.”
Stanley Hupfeld, former CEO of Integris Health, said for hospitals, cancer and heart health are the two most profitable. Everyone wants something in at least one of these fields that will set them apart.
While at Integris, Hupfeld helped build the relationship that still exists between the Integris Cancer Institute of Oklahoma and the ProCure Proton Therapy Center. The two facilities are next to each other on Memorial Road.
“I suspect that OU views itself — and appropriately so — as a tremendous cancer resource, and as such, it wants all the latest tools,” Hupfeld, Integris Family of Foundations chairman, said. “The debate, of course, is — would we do better if we could collaborate in hospitals rather than just compete?”