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Particle Therapy Clinical Trials
Published in Manjit Dosanjh, Jacques Bernier, Advances in Particle Therapy, 2018
Cai Grau, Damien Charles Weber, Johannes A. Langendijk, James D. Cox, Tadashi Kamada, Hirohiko Tsujii
Even if sufficient patients were available in principle, the impediments beyond credentialing and quality assurance as noted earlier can produce a biased sample of patients, resulting in a flawed trial. The major distortion in sample is patient preference. Another is payment for each treatment. Payment for the care of patients in the United States is not uniform. Medicare, the payment mechanism for most adults over the age of 65, does cover proton therapy. Younger patients are covered by private insurance companies according to policies that may be quite variable, or they may have to pay for treatment from their personal resources. To demonstrate the value of particle therapy compared with photons from computer images (in silico) is rarely considered satisfactory evidence by the gatekeepers at the insurance companies. Thus a biased sample could easily occur in the arms of a prospective trial.
Proton therapy
Published in Jing Cai, Joe Y. Chang, Fang-Fang Yin, Principles and Practice of Image-Guided Radiation Therapy of Lung Cancer, 2017
Clemens Grassberger, Gregory C. Sharp, Harald Paganetti
Proton therapy reduces the “integral dose" (total energy deposited in the patient) by about a factor of 2–3 compared to photon techniques [2]. This is independent of the photon or proton delivery technique (Figure 10.1 [3]). There is a true reduction in integral dose, other than in intensity-modulated photon therapy (IMRT) versus 3D conformal photon therapy, where the integral dose stays largely the same but the dose distribution can be shaped more favorably when using IMRT as it allows to redistribute dose within the irradiated area. Thus, from a purely dosimetric standpoint, proton therapy offers an advantage for all radiation therapy patients. There is clearly more sparing of normal structures with protons (Figure 10.2 [4]). Dosimetric advantages may, however, not necessarily translate into significant clinical gain.
Prostate cancer high dose-rate brachytherapy: review of evidence and current perspectives
Published in Expert Review of Medical Devices, 2018
Sunil W. Dutta, Clayton E. Alonso, Bruce Libby, Timothy N. Showalter
Healthcare cost modeling is difficult, and reimbursement rates are ever changing. There is a scarcity of cost analysis studies evaluating the different radiation treatment modalities, which not only includes brachytherapy but can range from IMRT, a highly conformal version of EBRT utilizing conventionally fractionated schemes (1.8–2.5 Gy per fraction in 20–40 fractions), to stereotactic body radiotherapy (SBRT), also highly conformal but using hypofractionated schemes (7–24 Gy per fraction in around 5 fractions). Halpern et al. evaluated different modality costs in a recent publication comparing brachytherapy alone, IMRT, SBRT, and proton therapy [57]. Brachytherapy was associated with the lowest costs (mean cost $20,213), followed by SBRT, IMRT, and proton therapy ($29,150, $39,720, and $54,132, respectively). Combination therapy costs were not reported. Similarly, Helou et al. showed SBRT and LDR to be less expensive compared to EBRT for low risk disease. The study also showed that LDR is more effective at quality adjusted life-years (QALYs) gained at its given cost [58]. One potential issue to implementing HDR brachytherapy into practice is costs to a facility, which can be evaluated using time-driven activity-based costing (TDABC). Ilg et al., in a TDABC analysis, found that personnel time required for two implants of HDR was costlier compared to delivery of LDR, exemplifying the importance of minimizing the number of implants as a cost reduction strategy [59]. As HDR brachytherapy utilization matures and long-term quality of life outcome are reported, cost analysis studies will be necessary to further justify its role given the positive trials thus far supporting its use.