Diagnosis: Rectal Cancer with Metastasis
Treatment: Radiation Therapy (Proton)
The health plan denied the requested service.
The health plan's determination is upheld.

This is the case of male patient who presented with metastatic rectal cancer. The patient was treated with chemo followed by a hepatectomy. The patient then developed lung metastasis and was treated with chemo followed by Stereotactic Body Radiation Therapy (SBRT). The patient later had a repeat SBRT lung. The patient had brain metastasis and was treated with surgery followed by SBRT and then stereotactic radiosurgery (SRS) for dural based lesion. Recently, right upper lobe (RUL) and right lower lobe (RLL) lung lesions progressed, and the patient is being evaluated for Proton beam. This is the subject of review.

The health plan's determination of medical necessity is upheld.

No, the requested health service/treatment of Proton therapy is NOT medically necessary for this patient.
Proton beam is medically necessary and appropriate in pediatric cancers, uveal melanoma, chordoma and chondrosarcoma of base of skull etc. There is no medical literature to support Proton beam for this medical condition. National Comprehensive Cancer Network (NCCN) guidelines do not support Proton beam for this clinical scenario.
This patient has widespread metastatic cancer with multiple recurrence in lung. he can be treated with palliative radiation using other technique like intensity modulated radiation therapy (IMRT). The attending physician has not provided any DVH (dose volume histogram) comparison of Proton beam vs photon-based radiation therapy (RT) suggesting any superior clinical outcome or dosimetric advantage of Proton over photon-based treatment. There is no justification for Proton beam. The attending physician mentioned that this is a retreatment of the lung, which is not sufficient to justify use of Proton beam for palliative RT.
Using particle-beam therapy rather than photons offers the potential for further advantages because of the unique depth-dose characteristics of the particles, which can be exploited to allow still higher dose escalation to tumors with greater sparing of normal tissues, with the ultimate goal of improving local tumor control and survival while preserving quality of life by reducing treatment-related toxicity. However, the costs associated with particle therapy with protons are considerably higher than the current state of the art in photon technology, and evidence of clinical benefit from protons is increasingly being demanded to justify the higher financial burden on the healthcare
In this case, patient has widespread metastatic cancer and there is insufficient data for Proton beam for metastatic cancer to lung. Conventional 3D CRT (3-Dimensional Conformal Radiation Treatment)or IMRT is safe, effective and medically appropriate. Proton beam is more costly and not shown to be clinically superior compared to conventional palliative photon beam RT.