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The American Journal of Managed Care February 2020
Care Coordination for Veterans With COPD: A Positive Deviance Study
Ekaterina Anderson, PhD; Renda Soylemez Wiener, MD, MPH; Kirsten Resnick, MS; A. Rani Elwy, PhD; and Seppo T. Rinne, MD, PhD
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From the Editorial Board: Jeffrey D. Dunn, PharmD, MBA
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Lisa M. Lines, PhD, MPH; Wayne L. Anderson, PhD; Harper Gordek, MPH; and Anne E. Kenyon, MBA
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Hsueh-Fen Chen, PhD; J. Mick Tilford, PhD; Robert F. Schuldt, MA; and Fei Wan, PhD
Preventive Drug Lists as Tools for Managing Asthma Medication Costs
Melissa B. Gilkey, PhD; Lauren A. Cripps, MA; Rachel S. Gruver, MPH; Deidre V. Washington, PhD; and Alison A. Galbraith, MD, MPH
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A Population-Based Assessment of Proton Beam Therapy Utilization in California
Arti Parikh-Patel, PhD, MPH; Cyllene R. Morris, DVM, PhD; Frances B. Maguire, PhD, MPH; Megan E. Daly, MD; and Kenneth W. Kizer, MD, MPH
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A Population-Based Assessment of Proton Beam Therapy Utilization in California

Arti Parikh-Patel, PhD, MPH; Cyllene R. Morris, DVM, PhD; Frances B. Maguire, PhD, MPH; Megan E. Daly, MD; and Kenneth W. Kizer, MD, MPH
This population-based analysis of patients with cancer in California found significant differences in proton beam therapy use by health insurance type, race/ethnicity, and socioeconomic status.

Proton beam therapy (PBT) is a type of radiation therapy (RT) used for certain cancer types because it minimizes collateral tissue damage. The high cost and limited availability of PBT have constrained its utilization. This study examined patterns and determinants of PBT use in California.

Study Design: Persons with diagnoses of all cancer types from 2003 to 2016 inclusive who had any type of RT were identified in the California Cancer Registry in this retrospective analysis.

Methods: Cross-tabulations were performed to summarize the demographic characteristics of the study population, both for individuals who received PBT and for those who received other RT modalities. PBT use patterns over time were assessed. Multivariate logistic regression models assessed the effects of demographics and health insurance type on receipt of PBT.

Results: Of the 2,499,510 people with a cancer diagnosis during the study period, 578,632 (23%) received some type of RT, and of these, 8609 received PBT (1.5%). PBT was most often used to treat cancers of the prostate (41.3%), breast (14.0%), eye (11.7%), lung (6.1%), and brain (6.0%). PBT use was highest in 2003-2004 and then declined over time. PBT use was significantly associated with being white or male, younger age, higher socioeconomic status, Medicare or dual Medicare-Medicaid insurance, uninsured/self-pay status, and proximity to treatment.

Conclusions: Significant differences exist in PBT use by demographics and health insurance type. The identified racial and socioeconomic disparities merit further investigation. More granular studies on both use patterns and effectiveness of PBT for specific cancers are needed to draw stronger conclusions about its cost-benefit ratio.

Am J Manag Care. 2020;26(2):e28-e35.
Takeaway Points
  • Patients with cancer with Medicare insurance coverage were more likely to receive proton beam therapy compared with patients with private insurance.
  • Compared with non-Hispanic whites, all other racial/ethnic groups had significantly lower odds of being treated with proton beam therapy, across various cancer types, after accounting for other relevant demographic and clinical factors.
  • Policy makers should consider data on both utilization patterns and comparative effectiveness to develop policies to ensure that proton therapy is used appropriately and that its use is limited to populations for whom there is evidence of benefit.
Radiation therapy (RT) is an integral part of cancer care, with some estimates indicating that approximately 40% to 50% of patients undergo RT during their treatment course.1-3 Technological advancements have resulted in the development of multiple modalities that deliver precise radiation doses to the tumor, resulting in less damage to surrounding healthy tissues. The most commonly used modalities are photon based and have evolved from conventional 2-dimensional to 3-dimensional (3-D) conformal radiation and intensity-modulated RTs.4 Proton beam therapy (PBT) techniques have evolved in parallel. The heavier mass of protons, compared with photons, allows highly targeted, maximal doses of radiation to be delivered to the tumor but not beyond it, which is theorized to result in fewer proximal and late effects for select cancer types, including subsequent malignancies.2 PBT is indicated for sarcomas and cancers of the brain and central nervous system (CNS) in children and adolescents, as concerns regarding late effects are particularly relevant for the cancer treatments in this population subgroup.5-8 PBT is also indicated for certain rare cancers in adults (eg, tumors of the skull base, eye, and spine) because of tumor location and concern about radiation damage to adjacent structures.9 Although there is little consensus regarding the comparative effectiveness of PBT for common adult cancer types,9 advocates continue to press health plans to cover PBT for treatment of prostate, breast, and lung cancers, among others. In California, efforts in this regard have also been directed to the Department of Managed Health Care, which provides regulatory oversight of the majority of health plans in the state.

The high cost and increased use of radiation treatments have spurred calls from national cancer policy groups for research to determine utilization patterns and relative value of specific radiation modalities to both patients and society.9,10 PBT has been available since the late 1980s, but its accessibility remains limited. This is due largely to high operational costs, leading many insurers to decline payment for PBT absent definitive evidence of its therapeutic superiority over other RT modalities. Additionally, high start-up costs of building PBT centers have limited the number of such sites, often causing patients to travel long distances for treatment.

Despite a recent increase in the number of proton centers under development in the United States, current and historical PBT utilization patterns are not well understood. The few national studies on this topic are confined to investigating PBT use among patients with prostate cancer using information with limited generalizability.11-13 Because the availability and development of PBT centers vary significantly by region, state-specific utilization patterns merit investigation.
We examined determinants of PBT use over time across all cancer types in California, a state with a large and diverse population. This study was undertaken in part to inform leadership of the Department of Managed Health Care about the statewide patterns and determinants of PBT use. California had 2 operating proton centers (Loma Linda University in Loma Linda and California Protons in San Diego) and 1 proton ocular center (University of California, San Francisco) during the study period.


Study Population

Individuals with a diagnosis of any type of cancer during the period 2003-2016 who had any type of RT during their first course of treatment were identified in the California Cancer Registry (CCR). The CCR is the largest population-based cancer registry for a geographically contiguous area in the world, collecting incidence reports on more than 160,000 newly diagnosed cancer cases annually. Although the CCR contains information on cases diagnosed from 1988 forward, cases diagnosed prior to 2003 were excluded because collection of information on the specific radiation modality started in 2003, prior to which PBT use was minimal.

Description of Variables

Patients with cancer were classified into 2 groups on the basis of radiation treatment modality: (1) individuals who received PBT and (2) those who received all other RT modalities, including photons, electrons, intensity-modulated RT, and conformal or 3-D therapy. Details of radiation treatment administered during the first course of treatment are captured in the registry through medical record review. International Classification of Diseases for Oncology, Third Edition codes were used to identify cancer sites.14

Information on primary and secondary payer at diagnosis was combined to create 6 categories of health insurance: private insurance (including Medicare with private supplement), Medicare only, Medicaid, dual Medicare-Medicaid coverage, county (including local publicly administered health plans), and uninsured/self-pay. Persons having Medicare-Medicaid dual eligibility are of particular interest from a cancer care perspective because disproportionate numbers of these persons have poorer access to care and worse outcomes compared with the general population consequent to advanced age and adverse socioeconomic circumstances.15,16 The uninsured/self-pay category included persons without insurance and those with any balance due after insurance payments because of deductibles or noncovered services.

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