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The University of Pennsylvania's new radiation therapy center is costing $144 million to build, is the length of a football field and contains some of the most complex and expensive medical machinery ever built. It is either a godsend to patients with intractable tumors or a stunning example of runaway health care costs. Or both.
The output of the exotic machinery is a proton beam, the latest way to zap away malignancies. In one room sits a cyclotron--220 tons of metal shaped like a hockey puck. The cyclotron's magnets and electric fields can accelerate subatomic particles to 60% the speed of light. It fires the protons through 100 yards of computer-guided piping into five treatment rooms. While a patient lies on a bed, a 33-foot-high, 100-ton motorized gantry spins around to zap tumors from the most effective angle.
Protons kill tumors just as X-rays do in the more conventional variety of radiation treatment, but in theory the protons are far more precise; they can release most of their radiation right onto a tumor and nowhere else. Supposedly proton machines will slash side effects and allow for higher doses that will cure more patients. "You will be able to do things with protons that you can't even conceive of now. It's the radiotherapy of the future," boasts radiation oncologist and entrepreneur James Schwade, who is raising money to build a proton treatment center at the University of Miami.
Penn's proton center, when it opens this fall, will be the sixth such center in the country. Four other proton-beam machines are under construction, and at least that many more are in various stages of planning. Penn's center was built with a $15 million donation from the Roberts family of the Comcast (nasdaq: CMCSA - news - people ) cable fortune, plus money from Penn's affiliated hospitals and the government. But most of the $1.5 billion that has been sunk into or committed to building proton centers has come from investors hoping to make a profit. Even the proton center at the august M.D. Anderson Cancer Center in Houston is mostly owned by various investors. (The other existing centers are at the University of Florida, Indiana University, Massachusetts General Hospital and Loma Linda University Medical Center in California.)
Protons offer advantages in certain rare spine, brain and eye tumors, as well as with kids, whose tissue is highly sensitive to stray radiation. Yet scientists have never proved in controlled clinical trials that protons work better or more safely than conventional therapies on common tumors. The cost controversy has especially erupted over their use in prostate cancer. Treating most prostate patients with protons "probably is not worth it," says Massachusetts General Hospital radiation oncologist Anthony Zietman. "There are perfectly good, much less expensive alternatives," such as surgery, X-rays and implanted radioactive seeds.
Winifred Hayes, a nurse whose research and consulting firm evaluates medical technologies for insurers and hospitals, says the proton-beam construction boom is driven more by a technology arms race among hospitals than by compelling medical evidence. "At a price tag of $150 million, the public deserves to have this question answered," she says. X-ray radiation therapy machines cost $3 million each; a big clinic would have several.
But patients are used to getting what they want, especially in cancer care, where any chance at living longer with fewer side effects is worth trying, especially if someone else is picking up the tab. Schoolteacher Mark Chalupsky of Carver, Minn. feared that prostate cancer surgery would render him incontinent, so he went to Florida last summer to get protons instead. "I had no side effects," he says. "I would play golf and go to the beach" after treatments. Medicare pays twice as much for a round of protons as for X-rays: $34,000 for eight weeks of therapy versus $16,000. Private insurers also cover protons, though they often require preapproval.
Proton beams are not new, but it took a while for them to move from the physics lab into medicine. The core technology, a particle accelerator called a cyclotron, was invented in 1929. It contains a vacuum chamber sandwiched between two magnets. The magnets keep protons spinning in the center while electric fields accelerate them. Some proton beams use a related machine called a synchrotron.
Physicists have long known that protons might have advantages for radiation therapy. X-rays zip through you; everything in their path gets at least some radiation. (Modern machines use several beams intersecting on the tumor to reduce this.) Protons slow down as they penetrate tissue and deposit most of their energy right before they stop. If you hit a patient with protons going at the right velocity toward the tumor, you should spare more healthy tissue.
Harvard doctors started using the physics department's cyclotron in the 1960s and got good results with certain spine and eye tumors. But few thought the technology could be made practical for routine hospital use until Loma Linda University Medical Center built a dedicated proton-beam machine in 1990. It was a big success. To date Loma has treated 13,500 patients, mostly those with prostate cancer.
Massachusetts General got its own machine in 2001 to replace the physics lab's; it was built by Belgium's Ion Beam Applications, which is also doing Penn's. Soon after, investors plunged in. Privately held ProCure Treatment Centers in Bloomington, Ind., started in 2005 by physicist John Cameron and Goldman Sachs (nyse: GS - news - people ) veteran Hadley Ford, is developing and financing many of the beam rooms. ProCure is backed by $70 million from Aubrey McClendon, an owner of the Oklahoma City Thunder basketball team, and is building centers in Detroit, Chicago, Boca Raton, Fla. and Oklahoma City. To inspire doctors to send traffic its way, ProCure sells minority stakes in its centers to oncology practices and hospitals. The projects are 80% funded by bank loans.
A fully operational proton center with four treatment rooms running 6 days a week, 16 hours a day--a typical usage--can dispense 40,000 treatments a year, generating $50 million in revenue and $18 million in pretax profits, says Ford. Ford aims to deliver a 15% to 20% annual return for his equity investors, more or less what they could get on a leveraged buyout pool, if not for the recession.
The centers have become magnets for politics. In Michigan the Beaumont hospital chain struck a deal with ProCure in 2007 and applied to the state for a license. Other hospital systems, including the University of Michigan and Henry Ford, protested, arguing instead for a consortium-run center. State regulators agreed. But Beaumont and ProCure refused to join and lobbied Michigan Governor Jennifer Granholm, who overruled the regulators last year.
In DuPage County, Ill., Northern Illinois University, a state institution with no hospital, decided it could put itself on the map by embracing protons. NIU got state approval in February 2008--and $6 million in earmarked federal funds, courtesy of Congressman Bill Foster. At the same time ProCure and Central DuPage Hospital pursued another center. Illinois rejected their project last March after NIU waged a loud campaign against having a second beam only 6 miles away. ProCure and Central DuPage appealed and got a license to build in November, but the brouhaha continues. NIU's representatives, citing ProCure's attorney's campaign contributions to then governor Rod Blagojevich, suggest impropriety in the reversal. "[Our center is] not a cash register for greedy investors," says NIU spokesman Gary Mack. ProCure's Ford says any assertion of wrongdoing is baloney.
X-ray therapy has improved in recent years. New machines sculpt multiple beams so that only the tumor gets high radiation doses. Zietman of Mass General worries that older prostate patients who don't even need treatment at all will, once excited by Internet tips, rush off to get proton therapy. Serious side effects from radiation therapy can surface years later. Zietman had one patient who was hospitalized with rectal bleeding after proton therapy.
The scientific debate could be resolved with a large trial in which patients were randomly assigned to X-rays or protons and tracked for years. Proton proponents say that would be a waste of time. "The laws of physics prove beyond a shadow of a doubt that proton radiation" is better, insists prostate cancer survivor Robert Marckini of Mattapoisett, Mass. He got proton therapy in 2000 at Loma Linda and was so impressed that he wrote a book and started protonbob.com to tout its virtues.
The M.D. Anderson center is starting a trial this month that will compare protons to X-rays in 200 lung cancer patients. Radiation oncology chief James Cox hopes that protons will increase the cure rate from 25% to 50% for certain lung cancer subtypes. But he says a prostate cancer trial is tough because most patients know what they want.
Radiation oncologist James Metz, who is overseeing construction at Penn, says its doctors are committed to trials and will work under less financial pressure than the docs pushing patients through investor-owned equipment. Penn plans to cap the number of prostate patients at 20% or 30%, so kids and other people with harder-to-treat tumors will be able to use it. But that won't end the debate about whether medical costs are racing too far ahead of medical results.
By The Numbers: Beam Blowout
$144 million to build a five-treatment-room proton-beam therapy center.
2 to 3 years to construct a proton-beam facility.
20,000 patients treated with protons to date in the U.S. (all with tumors).
60 seconds of contact between the proton beam and patient during each session.
$841 cost to Medicare for one session of proton therapy.
$411 cost to Medicare for one session of X-ray-beam therapy.
Sources: University of Pennsylvania's Roberts Proton Therapy Center; ProCure; National Association for Proton Therapy; Radiological Society of North America; Centers for Medicare & Medicaid Services (level II proton-beam radiation therapy in hospital setting); CMS (intensity-modulated radiation therapy in hospital setting).
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