Proton beam partial breast irradiation for early stage breast cancer: a Not-so-costly alternative

Reporter: Annemarie Fernandes, MD
The Abramson Cancer Center of the University of Pennsylvania
Last Modified: November 7, 2014

Presenter: Valentina Ovalle, MD
Presenter's Affiliation: MD Anderson Cancer Center


  • Breast cancer is the most common cancer found in women. Patients are generally treated with mastectomy or breast conserving therapy that involves a lumpectomy followed by adjuvant radiotherapy.
  • The whole breast is the traditional target for adjuvant radiation therapy and is delivered over 3-6 weeks. However, partial breast irradiation in a very select group of women is becoming more common practice.
  • Partial breast irradiation is typically administered in a shortened time period- typically over 1 week (5 days, 2 treatments/day for a total of 10 treatments).
  • Two general approaches for delivering accelerated partial breast irradiation (APBI) involve brachytherapy or external beam radiotherapy.
  • External beam radiotherapy can be delivered using proton beam radiotherapy or photon beam radiotherapy.
  • Proton therapy may offer an advantage over conventional photon therapy as the proton beam deposits most of its energy at a specific depth so the radiation dose beyond that depth is minimal and side effects would be expected to be less.
  • Dosimetric and clinical results of APBI with proton beam radiotherapy have been published with with promising results.
  • A limitation of using proton therapy is the reluctance of insurance companies to cover treatment due to the perceived high cost.
  • The purpose of this study was to determine the cost of P-ABI relative to other established radiation treatments for early stage breast cancer

Materials and Methods

  • Using the 2014 Standard Medicare Payments for both professional and technical charges, the Author's compared Medicare Allowable Charges (MAC) across breast irradiation techniques taking into account frequency of CPT codes
  • Whole breast irradiation (WBI) and ABPI were compared
    • 4 techniques for WBI were studied: 3D conformal radiotherapy (3DCRT) over 6 weeks, 3DCRT over 3-4 weeks, intensity modulated radiotherapy (IMRT) over 6 weeks and IMRT over 3-4 weeks.
    • 4 techniques for ABPI were studied: proton beam radiotherapy, linac- based radiotherapy and 2 forms of brachytherapy: Savi and Mammosite
  • The technical and or professional component of every procedure CPT code was evaluated and broken down by preparing for treatment: simulation, CT guidance with fiducials, immbolization, etc.


  • The total MAC ranged from $6,771-$19,599 with a mean of $12,784
    • P-APBI = $13,833, WBI = $13,149, APBI using 3DCRT = $6,771
  • IMRT using standard fractionation had the highest allowable charges, exceeding the mean by over 50%
  • The technical components varied from $5,157-$16,617 while the professional MACs were less variable: $1,614-$3,245

Author's Conclusions

  • The Author's conclude that MACs for APBI with proton beam therapy are comparable to other APBI and WBI techniques
  • APBI using proton beam radiotherapy has lower payer costs than WBI with IMRT and APBI with multi-lumen brachytherapy
  • It is likely that the personal financial burden for patients is also lowered with a 1-week regimen, compared to a 3-6 week regimen.
  • As clinical experience is gained through clinical trials, payer costs for P-APBI should not be an impediment when considering treating patients with this emerging modality

Clinical Implications

  • In light of the current healthcare spending environment and the reluctance of insurance companies to cover proton beam radiotherapy, the Author's present intriguing results on the cost of APBI using proton beam radiotherapy.
  • Using MACs, they found that the cost of APBI with proton beam therapy is comparable to other APBI and WBI techniques. However, the cost of APBI with 3DCRT was the lowest.
  • To further the author’s argument, the current analysis does not take into account the added convenience of a 1-week treatment for patients undergoing APBI and the decreased costs for travel, lodging, and missed work that may result compared to a longer treatment course.
  • The technical components of the total MACs were much more variable than the professional components. This is likely related to variability with billing and implementation of radiation planning, image guidance and other technical components involved with the treatment of radiation therapy.
  • Although encouraging data for breast cancer patients, these results only apply to a select group of women who are candidates for APBI. Similar cost analyses should be performed in other disease sites to help justify the use of proton beam radiotherapy for other patients.


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