SINGAPORE – Proton beam therapy (PBT) is touted as a precision radiation tool to kill cancer cells, causing less damage to surrounding healthy cells than conventional radiation.
Dr Michael Wang, who chairs the division of radiation oncology at the National Cancer Centre Singapore (NCCS), said PBT reduces radiation exposure to nearby healthy tissues and organs, and “potentially” reduces the risk of developing secondary cancers due to radiation. So it can be used more aggressively to kill off more cancer cells.
Since the middle of 2023, Singapore has joined a handful of countries in the region offering PBT to treat cancer. Three places here offer this treatment: Mount Elizabeth Novena and the Singapore Institute of Advanced Medicine Holdings (SAM) at Biopolis have one treatment gantry each, while the NCCS has four treatment gantries.
The rotating gantries are the PBT’s treatment arms, with each sited in its own room, away from the cyclotron that divides and speeds up the protons for use.
Since its introduction, only about 300 people have been treated with PBT, although thousands of cancer patients undergo radiation therapy every year.
The sticking point is the high cost. The cost of the treatment, about 2½ to three times that of conventional radiation therapy, can be prohibitive. So if radiation treatments cost $10,000 to $30,000, the cost of PBT could range from $20,000 to $90,000.
Also, while the PBT treatment may have fewer side effects, a patient’s survival rate after the treatment has not been proven to be superior to conventional radiation for the majority of cancers.
To keep a lid on possible runaway cancer treatment costs, the Ministry of Health (MOH) has drawn up a list of cancers and conditions for which PBT can be used. PBT cannot be used for cancers or conditions not on the list, no matter whether the patient and the doctor think it might be beneficial.
This is aligned with the objective of the Cancer Drug List (CDL) that MOH introduced in 2022 for proven cancer therapies that can receive MediShield Life, Integrated Shield Plan (IP) and MediSave coverage – to prevent money from being spent on expensive but unproven treatments.
As Health Minister Ong Ye Kung explained in September 2022: “Ultimately, someone still pays for it. In this case, rising cancer drug prices will feed into insurance premiums. Private hospital IP premiums have already gone up by around 20 per cent over the past few years. At this rate of increase, in five years’ time, someone in their 50s probably has to pay about $300 more in annual premiums.”
The same principle applies for PBT. If the cost of radiation treatment for thousands of people triples every year, insurance premiums will definitely go up.
So MOH has decided that the cancers for which PBT is allowed insurance coverage are either in children or young people for whom the risk of getting secondary cancers could impact their lives far more than it would in an older person; or for cancers in sensitive areas of the body, such as in the head and neck, or prostate.
MOH does not provide any subsidy, although its spokesman said MediShield Life and MediSave do provide some coverage “pegged at existing limits of their conventional radiation therapy treatment, for a specified list of medical conditions approved by MOH for proton therapy”.
MediSave withdrawal ranges from $80 to $2,800 and MediShield Life claims range from $300 to $2,800 per treatment. There is a different limit for PBT used for the central and peripheral nervous system, where the limit is for per course of treatment and that is $7,500 for MediSave and $10,000 for MediShield Life.
This would put PBT beyond the reach of 30 per cent of the population who have only the basic MediShield Life insurance, even if the cancer that afflicts them is on the MOH list for PBT treatment – unless they qualify for and are granted MediFund coverage, the government safety net to help the poor afford their medical treatment.
As it stands, PBT is essentially an option only for close to half the population, those with IPs that give good coverage for PBT treatment. Although 70 per cent of the population has IPs, not all insurers provide sufficient coverage.
Different insurers provide different coverage. For those with private hospital IPs, insurance pays between $30,000 and $100,000 per year. Coverage for those with IPs pegged at B1 class range from $15,000 to $100,000 per year.
MOH cannot be faulted for wanting to limit the use of PBT, since allowing it to be freely used will inevitably drive up healthcare costs significantly. Insurance premiums might also rise to the point where many may have to opt out of IP coverage.
But where patients are concerned, some of their major considerations are having fewer side effects, getting rid of more of the tumour, and facing a lower risk of getting secondary cancers.
Today, even if a patient wants to foot the full bill himself for PBT treatment, he is not able to do so for cancers not on the approved list.
Meanwhile, with six very expensive treatment gantries here – each PBT machine costs between $80 million and $100 million – having just 300 patients in a year seems to be a gross under-utilisation of the equipment.
Perhaps MOH could ease its grip on who can receive PBT, while ensuring that its use does not push up healthcare cost for everyone.
It could do this with a two-tier system. The first tier would comprise the current PBT-approved list of cancers and conditions that can be covered by IPs, MediShield Life and MediSave, subject to existing caps.
The second tier would be all other cancers requiring radiation treatment. But for this tier, coverage even by private insurers offering IPs should be capped at conventional radiation rates.
Patients who want to opt for PBT would have to top up the difference in cash. This way, their use of PBT will not impact premiums, but would still give them the choice of therapy.
To be fair to all patients, MOH should also offer similar subsidy for PBT treatment that it does for conventional radiation – although in reality, it will still leave a huge portion of the bill to be paid for by the patient.
If this scheme were to be adopted, it would mean insurers would no longer be allowed to cover conventional radiation treatment on an “as charged” basis.
It would again reflect the CDL model where MediShield Life places coverage caps for different cancer treatments, and the IPs’ coverage is, currently, a few times of that amount – for example, an IP might cover five times the amount covered by MediShield Life.
This would have an added advantage of controlling prices for radiation treatment in lieu of the blank cheque that comes with the current “as charged” model.
It would also allow more foreigners to come for treatment, since any cancer can be treated with PBT. This would help the three institutions offering PBT to recover the costs of the machines more quickly, and hopefully, result in reduced rates.
This would be a win-win for all parties. MOH would be able to keep a lid on costs and patients would have the freedom of choice should they want to pay for it.
