Such financial realities can put undue pressure on doctors to treat prostate cancer cases, which are relatively simple and quick—and therefore most profitable. Treating a child with cancer, in contrast, can tie up a facility for three or four times as long, adding to the patient bottleneck and slowing an indebted center's ability to repay its loans. "There's definitely pressure from a few of the investors to treat only prostate cancer," acknowledges James Cox, the top radiation oncologist at M.D. Anderson's proton center. Adds Allan Thornton, the medical director at the Midwest Proton Radiotherapy Institute in Bloomington, Ind.: "I've got people breathing down my neck who want to make money on this place." He aims to make prostate cancer about 30 percent of the cases at his institution; Cox, 50 percent at his.
Nevertheless, hospitals say demand for proton beam therapy is ballooning, driven in large part by the huge number of prostate cancer diagnoses—about 186,320 a year—and the favorable impression many prostate patients have of the therapy. Loma Linda, which has been using protons to treat men with prostate cancer since 1991, has published promising results. One study, for example, found major rectal and urinary side effects among less than 1 percent of Loma Linda patients; it didn't specify rates of sexual side effects. Those types of problems are risks associated with other radiation treatments or surgery.
Some men who have received protons at Loma Linda have been so thrilled with their experience that they've become among the technology's biggest boosters, spreading the word through books, chat rooms, support groups—even PowerPoint presentations at churches and clubs. One Loma Linda patient, Robert Marckini, founded what's now a 3,340-member proton therapy support group, the Brotherhood of the Balloon, that has been instrumental in increasing awareness of the technology among prostate patients. "Almost every one of [the members] learned about proton beam therapy from another patient," he says, not from a doctor.
But certain doctors—not to mention the occasional patient who has experienced side effects from proton therapy—wonder whether the high-tech allure of protons hasn't outpaced the science. "Because of Internet buzz, the morbidity associated with proton beam therapy is underappreciated," says Anthony Zietman, a radiation oncologist at Mass General who specializes in prostate cancer. Many of his patients, he says, are surprised to learn that proton beam therapy exposes the bladder and rectum to high doses of radiation and does, in fact, carry a significant risk of causing impotence. Although preliminary research has suggested protons may be superior to conventional radiation for prostate cancer, there's a lack of randomized studies (the type doctors consider most rigorous) comparing the two—and standard radiation techniques are improving all the time.
The lingering questions about prostate cancer are helping to fuel a debate over the location of new proton beam centers and the pace of expansion. Experts who believe prostate cancer should be widely treated estimate there could be a need for scores of new centers. Others contend that five to 10 evenly distributed academic research centers could better serve the rare patients who most need protons—and help determine whether the therapy should be extensively used to treat prostate and other common tumors.
"Prostate mill." In suburban Chicago, the two expansion strategies are at odds. Two centers have been proposed within just a few miles of each other. One would be run by Northern Illinois University as an academic facility; the other by Central DuPage Hospital, which has partnered with ProCure. "To roll out multiple facilities competing against each other is illogical and a waste of resources," says Thornton. An Illinois planning board validated that viewpoint in early April when it denied the latter proposal. Thornton adds that bottom-line considerations could turn a for-profit facility into what he calls a "prostate mill."