Arnold Kling  

Premium Medicine: Proton Therapy

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From the New York Times.


The machines accelerate protons to nearly the speed of light and shoot them into tumors. Scientists say proton beams are more precise than the X-rays now typically used for radiation therapy, meaning fewer side effects from stray radiation and, possibly, a higher cure rate.

But a 222-ton accelerator — and a building the size of a football field with walls up to 18-feet thick in which to house it — can cost more than $100 million. That makes a proton center, in the words of one equipment vendor, “the world’s most expensive and complex medical device.”

...Some experts say there is a vast need for more proton centers. But others contend that an arms race mentality has taken hold, as medical centers try to be first to take advantage of the prestige — and the profits — a proton site could provide.

“I’m fascinated and horrified by the way it’s developing,” said Anthony L. Zietman, a radiation oncologist at Harvard and Massachusetts General Hospital, which operates a proton center. “This is the dark side of American medicine.”


The kicker:

The stray radiation, though, from the newest form of X-rays, called intensity-modulated radiation therapy, is already low, diminishing any advantages from proton therapy.

My father was diagnosed with esophageal cancer, one of the most difficult cancers to treat, in part because the surrounding tissue that might be damaged by stray radiation includes the heart and lungs, as well as healthy esophageal tissue. So the issue of being able to target radiation is something I can relate to.

But the Times article does not give us enough information to make cost-benefit estimates about proton therapy. If intensity-modulated radiation therapy costs less and is roughly equivalent, then these proton therapy centers are indeed a case of our health care system run amuck. In this case, you cannot blame private health insurance--the article says that it is Medicare, i.e., you and me, footing the bill.

Articles like this make me want to plug my book even harder. The use of what I dub "premium medicine" is, in my telling, the central facet of the U.S. health care story.


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COMMENTS (6 to date)
Matt writes:

It will be built, a rich man will build it and rent it out to the less rich.


Then we get efficient, running those cancer patients through, 10 minutes at a time. Each oncologist is responsible for the digital settings, the patient is put on an assembly line, and heads for the green door for his 10 minutes under the sun. The machine reads his bar code, tells him, in computer generated voice, "Be still Mr. Jones", he moves in, zap, and he moves out.

John writes:

"Premium" usually has a cost and quality component, except in medicine. I am a practicing physician and just started blogging on this problem, HealthCareWaste at blogspot.

Bruce G Charlton writes:

I'm very skeptical that anything along the lines of technocratic cost-benefit analysis can help much with this type of decision (ie. whether or not to fund proton therapy).

Costs of a new technology are very fluid, and usually go down over time. Benefits are hard to capture in a single statistic - quite often a new treatment generates large benefits for some patients , no benefits and no harms for others, and the treatment harms some other patients. An average treatment effect may be nonsensical since no individual patient ever experiences the average effect.

Cost benefit analysis is easily manipulated to stop new treatments. For example, if a study population includes wrongly-diagnosed patients, and the results are diagnosed by 'intention to treat' methods, then almost any medical treatment will appear feebly effective.

This was done for the breakthrough intiviral influenza treatment Relenza by the UK state organization NICE which decides what gets funded by the NHS. By including people who (as it turned out, following testing) did not have the flu virus in the study population, the average effectiveness of Relenza was diminished.

In other words, there was a bimodal distribution of results - those patients with flu had the illness significantly shortened (by several days), those who (as it turned out) did not have flu did not get any benefits. The average effectiveness therefore depends on the proportion of patients in each category - in the study reported by NICE the avarega effectiveness was that the illness was shorted by a day, which NICE declared was insignificant given the high cost of the new drug - so the drug was not made widely available.

Usually, this kind of therapeutic nihilism will be justified, because most new inventions don't work very well - but it will also stop treatments which might have evolved to the point of being amajor breakthrough.

In a nutshell - it is difficult to determine effectiveness, and costs are chageable - so cost- effectiveness is often a meaningless concept; and technocracy in practice lacks both validity and objectivity.

The answer? Allow markets and let the market decide - if possible.

DeliberatelyMisunderstood writes:

There are other costs than the building of the photon accelerator. Magnetic fields cause the photons to orbit, and the photons pass through "gaps" that accelerate it, until eventually a tiny beam can be created. This whole process takes time, a team of specialized technician/particle physicists, and a great deal of energy to keep the thing going, even with a somewhat recent reduction in that arena (energy) through the use of super-conducting magnets.

Daublin writes:

Matt writes:
It will be built, a rich man will build it and rent it out to the less rich.

Matt, I wish it were legal to do that sort of thing. Once you are doing anything remotely medical, however, an American cannot simply do what they want. The state will decide how it runs, who is allowed to work on it, and how much may be charged to use it. The rich man will get scraps of freedom here and there as exceptions rather than the rule, and those scraps will be billed as radical market-driven experiments.

I do wish that socialist-minded folks would concentrate on offering services rather than seizing existing ones.

Ambulance Nurse writes:

I know that esophageal cancer can be treated seventy-per-cent on the first stage. The problem is that desease has no symptoms in the beginning.
Ambulance Nurse

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