Context
Proton beam therapy (PBT) has been described as a technological innovation that may have the potential to disrupt and transform approaches to cancer treatment. However, its high cost and an absence of evidence to support its clinical effectiveness — for many types of cancer — has resulted in limited patient access and raised questions about its value in real-world settings.1 Nonetheless, its global adoption has been rapid. There are 63 facilities providing PBT worldwide,2 an additional 32 facilities are under construction,3 and 16 more are in the planning stages of development.4
PBT is an advanced radiation treatment technology that is intended to reduce the radiation dose to surrounding healthy tissue compared with photon radiotherapy. This may improve short- and long-term patient outcomes, and increase capacity to treat pediatric patients and those with cancer who would be untreatable with photon therapy due to proximity to radiosensitive structures.5
At this time, there are no PBT treatment centres in Canada. Patients requiring treatment are referred to out-of-country facilities. One research facility in Vancouver provides PBT for the treatment of intraocular melanomas, but all other cancers require PBT equipment that is only available in other countries. However, Health Canada approved the Mevion S250 in 2015. The Mevion S250 is expected to treat approximately 350 patients per year,6 and can be used to treat cancers other than intraocular melanomas.
Older, multi-room PBT systems require the physical space of a football field and cost around $200 million. The Mevion S250, by comparison, is a single-room system that costs approximately $25 million.7 Its size allows for integration into existing hospitals, and improves access to radiation oncology and medical oncology services and expertise.8 It is unclear if retrofitting a Mevion S250 would require extensive structural changes to an existing facility.
The extent of the clinical demand in Canada for this therapy is unclear. This is likely due to the fact that many of the provinces that fund it only refer the highest-priority patients. In some instances patient cases may be too complex to be treated out of country.9 As well, the treatment program requires patients (and their caregivers) to be away from home for up to eight weeks, which for some families is not an option. As such, if PBT were available in Canada more patients may be referred by physicians, and more patients and caregivers may accept the treatment.
The purpose of this Environmental Scan is to provide information on the use and funding of PBT that may be useful for strategic planning purposes at the provincial and national level.
Next: Objectives
Objectives
This CADTH environmental scan reports on the criteria used to select patients for out-of-country referrals across Canadian provinces. It also compares Canadian practice with those of two other countries with similar, publicly funded, health care systems.
This report summarizes information obtained through a literature search and a survey of key informants. The objectives of the Environmental Scan are to:
- Identify which jurisdictions are considering installing PBT, making decisions on which patients should receive PBT, and sending patients out of country for PBT.
- Determine how out-of-country PBT is funded.
Previous: ContextNext: Methods
Methods
The findings presented within this Environmental Scan are informed by responses to the Proton Beam Therapy Survey (Appendix 1), gathered between November 4, 2016 and January 14, 2017, and by a limited literature search.
The literature search was conducted to identify relevant literature from other countries on their practices regarding PBT. Citation searches were made for key references, and reference lists from relevant papers were scanned to identify additional papers. Grey (unpublished) literature was identified by searching relevant sections of the Grey Matters checklist (http://www.cadth.ca/resources/grey-matters).
Table 1: Selection Criteria for Literature Search
| Population |
Adults and children with cancer |
| Setting |
Health care facilities |
| Intervention |
Proton beam therapy (PBT) |
| Results |
PBT practice, usage and cost patterns across Canada and internationally |
Survey responses were collected from key jurisdictional informants involved in the management of patients with cancer or the funding of the therapy. Informants were identified by CADTH staff, through professional and clinical networks, or referred through other respondents. A 14-question survey was developed and revised following internal review. The final survey was distributed via email to individuals in all provinces across Canada. Survey recipients were also asked to distribute the survey further to their colleagues, as appropriate. The survey questionnaire is provided in Appendix 1 and the list of participating provincial organizations in Appendix 2.
The survey included dichotomous, nominal, and free-text questions. Quantitative dichotomous (for example, Yes/No) and nominal variables (for example, a list of options) were summarized descriptively by jurisdiction. Open-ended qualitative responses were categorized by theme and summarized narratively. While all provinces were represented by the survey, territories were not represented. When more than one response was received per province and conflicting data were provided, we referred back to the provincial health ministry or cancer agency for clarification.
This report also includes relevant information from countries with publicly funded health care systems that do not currently have access to PBT and must send patients out of country for treatment.
Previous: ObjectivesNext: Findings
Findings
The findings of this report are presented by research question.
Which provinces and countries are considering purchasing PBT within the next five years and what are the preferred sites?
Canada
The survey responses indicated that three provinces — Alberta, Ontario, and Quebec — are considering purchasing PBT within the next five years. The preferred locations for PBT systems have not been finalized but would likely be cities with proximity to the largest pediatric oncology populations, access to radiation oncologists and medical oncology services and expertise, and the space to accommodate PBT equipment. The Alberta survey response reported that Edmonton and Calgary are being considered for PBT. In Quebec, Montréal would be the most likely city for PBT, and Ontario has not yet determined the preferred location.
A Proton Treatment Facility opened in 1995 in Vancouver. This facility is used exclusively for the treatment of melanoma of the eye.10 Its fixed beam is not suitable for other cancer types.11
United Kingdom
In the UK, two publicly funded PBT sites are currently under construction in London and Manchester. The Manchester site will be operational in 2018, and the London site in 2019.12 These cities were considered by the National Health Service (NHS) to be the most suitable for PBT construction because they provide the best geographical access to patients, and are able to provide optimal clinical services. These services include: access to integrated cancer care by a multidisciplinary team, proximity to radiotherapy centres, access to medical imaging equipment (CT, MRI, and positron emission tomography) for treatment planning, and the availability of pediatric and neurosurgical expertise.9 A privately funded centre in Newport, Wales, will be operational in 2017.13
For more than 25 years, PBT has been available at the Clatterbridge Cancer Centre near Liverpool for the treatment of some cancers of the eye.14
Australia
There are no existing PBT sites in Australia. However, in 2016, the Victoria Ministry of Health provided $50 million toward the establishment of Australia’s first PBT centre in Melbourne.15
Which provinces and countries send patients out of country for PBT?
Canada
The survey responses reported that five provinces currently refer patients out of country for PBT to the US. These include Alberta, Saskatchewan, Ontario, Quebec, and Nova Scotia. Of the provinces that are not currently referring patients out of country, British Columbia plans to do so within the next year. Manitoba, Prince Edward Island, New Brunswick, and Newfoundland and Labrador are not certain they will fund out-of-country PBT in the future.
The survey responses reported that Quebec set up a formal committee to review the selection of referral sites. The criteria include consideration of wait times and language barriers. While no official criteria have been used to select referral sites by other provinces, respondents reported that decisions regarding referral sites are often determined by:
- A history of collaboration
- Sites that already have high volumes of patients
- Experience and access to pediatric oncology expertise.
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http://www.proton-therapy.org/map.htm
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