Hospital Impact—Cancer patients deserve fair, timely coverage decisions for proton therapy

Micrograph of small cell lung cancer
Even as proton therapy is increasingly used to treat certain cancers, many insurers still refuse to cover it. (Michael Bonert/CC BY-SA 3.0)
Daniel E. Smith
Daniel E. Smith

In the rapidly advancing field of medical technology, progress often outpaces payment policy. This is certainly the situation when it comes to innovations in modern cancer care. Case in point: proton therapy.

Proton therapy, a form of radiation therapy that precisely targets cancerous cells with minimal damage to healthy tissues, is often a safer and more effective method of treatment than traditional radiotherapy. But coverage policies have not kept up with the advances in medical technology, and unfortunately, patients who may benefit most from this treatment can find it difficult, if not impossible, to access.

Today, The Alliance for Proton Therapy Access, of which I am executive director, is launching a national campaign, "Tell Insurers: Fight Cancer, Not Me," to advocate for increased patient access to proton therapy. As a kickoff to the campaign, the Alliance issued letters to dozens of insurers across the country, requesting clarification of their decision-making processes and policies regarding proton therapy treatment. Patients and their healthcare providers cannot be left in the dark about how and why a procedure is—or is not—covered.

Our campaign seeks to help alleviate unnecessary emotional and physical stress that occurs when insurance companies deny or delay coverage for treatment that has been recommended by a physician as the best course of care for a specific diagnosis. The Alliance’s campaign rests on three fundamental tenets: 

  • First, there should be timeliness; cancer patients deserve prompt answers on whether their insurance provider will cover proton therapy treatment. Cancer patients don’t have time to waste on complicated and opaque insurance appeals processes. 
  • Second, there should be transparency. A patient should understand exactly why their proton therapy is approved or denied. This is only possible if payers release data to the public so it can be analyzed by academics and policymakers. 
  • Finally, fairness should underpin insurance coverage decisions. People who have cancer deserve a consistent approval process that evaluates proton therapy in the same manner other proven cancer treatments. The medical necessity of a cancer therapy should be based on the recommendations and analyses of experts in the field, which in this case means radiation oncologists with proton experience rather than insurance claims officials. 

For example, despite the fact that the National Comprehensive Cancer Network recently published guidelines for the use of proton therapy for head and neck cancers, patients with these cancers are still experiencing insurance denials despite the published guidelines and the professional recommendation by their oncologist.

Cancer protocols, like the insurance policies that cover them, are becoming increasingly individualized. Today, doctors are able to customize a plan for each patient they treat that takes into account many different factors. These myriad options, while positive for the patient, create a complicated scenario for insurers who are slow adopters to newer treatments. This must change. 

The benefits of proton therapy are remarkable. It allows radiation oncologists and their medical teams to direct high-energy particles at cancer cells without leaving deposits of radiation in nearby healthy tissue. This precision reaps significant benefits. Clinical evidence shows that patients undergoing proton therapy are at a reduced risk of common radiation side effects like low blood counts, necrosis along the beam’s pathway, fatigue and nausea, thereby improving the patient’s quality of life.  

Yet, even as proton therapy is increasingly used to treat certain cancers, such as cancers of the lung and breast, many insurers still refuse to cover it. Aside from unfounded claims of “the science not being there,” payers often cite cost as their main explanation. This is a misleading argument since the overall sticker price for proton therapy can be less expensive than traditional radiotherapy. 

In their evaluation, insurers are not taking into account the “downstream” savings of proton therapy. Patients don’t incur as many additional healthcare costs or follow-up hospitalizations or treating secondary cancers as they may with conventional radiation. This is a win-win for patients and their insurers.

The progress we’ve realized in fighting cancer should not be undermined by insurance policies that have not kept pace. All cancer patients deserve timely access to the best available treatment recommended by their physicians. And they deserve an insurance process that is timely, fair and transparent. 

The Alliance stands ready to work with the insurance industry, but we will not rest until all patients have access to the proton treatment their doctors recommend. Fighting cancer is hard enough. Patients shouldn’t also have to fight their insurance companies for the coverage they need at one of life’s most vulnerable moments.  

For years, I have fought alongside patients to influence positive change so that individuals diagnosed with cancer know that there is hope, that they have options, and that those treatment options are available to them when they need care. I hope to do the same for patients for whom proton therapy offers the best hope for survival.

Daniel E. Smith is the executive director of the Alliance for Proton Therapy Access and the former president of the American Cancer Society’s Cancer Action Network.