Don't Mention the War

Last year the Danish government announced that it will finance a national particle therapy facility together with some private funding agencies. Two applications were submitted for evaluation:

• The Proposal for a Proton Therapy Center at Rigshospitalet (located in Copenhagen)
• The Danish National Center for Particle Radiotherapy (located in Aarhus)

and of course there is a strong interest from each side to host this project. Naturally, since I am part of the Aarhus Particle Therapy Group, I will right out admit I am naturally in favour of our project in Aarhus.

The plan is now that an international expert commission is being setup by the ministry of health. That commission will then evaluate those two applications and give a suggestion where to place such a facility.

If you compare those two applications, you will see that they both apply for a 3-gantry treatment facility. Copenhagen lock themselves on a cyclotron solution, where we in Aarhus are also open to a synchrotron based solution.

Basically the differences can be summarized here:

Copenhagen	Aarhus
3 treatment rooms with 2 gantries	3 treatment rooms with 2 gantries, +1 research room
3rd gantry will be installed later	3rd gantry will be installed later, a fourth treatment room with gantry can be added
Protons	Protons
Cyclotron	Cyclotron or Synchrotron
1000 patients per year	1000 patients per year

So basically what we apply for is rather similar.

What about the costs? If you compare those budgets, you will note that the prices of the equipment and the building are comparable too.

	Copenhagen	Aarhus
Equipment	450 mio. DKK	475 mio. DKK
Building	382 mio. DKK	295 mio. DKK
Supply systems and lines	195 mio. DKK	(incl. in building)
Purchase and demolition of Rockefeller Building	147 mio. DKK	(none)
Total	1174 mio. DKK	770 mio. DKK
Optional 3rd gantry	(not mentioned)	75 mio. DKK

Copenhagen need to build in the middle of the city, whereas we in Aarhus have a pristine green field adjacent to the New University Hospital. This means that the expenses for the Copenhagen proposal are significantly higher than the Aarhus solution, since a building has to be demolished first (they have simply a lack of space in Copenhagen). The "supply lines" cover, as far as I heard, establishing extra power for the facility, please correct me if I am wrong here. The annual operational costs are also similar.

There has been a few articles in the Danish press about the two applications. None of the Journalists managed to actually compare the two budgets, so basically the message was that Aarhus offeres particle therapy at dumping prices. Yeah right.

In addition, I hear a lot of weird arguments, e.g. such a facility MUST be build in Copenhagen, since it is the capital city, and it has a proximity to the airport.

Huh?

How many of the existing facilities are located in capital cities? Lets pick some of the most famous ones: HIT is in Heidelberg (147.000 inhabitants, 1hours drive to next airport). PSI is in Villingen. The Swedish facility is built in Uppsala, and not Stockholm. Why is that so? These research institutions simply had the longest track record in terms of particle therapy! I don't get the point of the closeness of an airport either, since you can reach any point within a few hours in DK by car, and sorry guys... particle therapy is not that acute.

Now, today this conflict took a very curious turn, as Copenhagen announced in Dagens Medicin that they will cut the price 75 % (login required to view link). What is going on?
It seems that Copenhagen suddenly decided to go for a single gantry facility by Mevion, formerly known as StillRiver. To me this looks like a very poor decision. The Mevion facility has been controversial for a long list of reasons. In a scientific article by Schippers and Lomax they list some of the issues with this facility:

• the very compact design of the cyclotron, may lead to large beam losses and resulting activation. 
• repetition frequency of synchrocyclotrons are typically 1kHz which limits applicability of the different pencil beam scanning methods.
• There is no beam analysis and no magnets in the beam path, in other words an energy selection system is missing. This means that the beam will have a poor distal edge, always looking as if it traversed 25-30 cm of material, e.g. when treating head an neck cancers. This limits possible treatment planning techniques, such as patch fields.
• Neutron contamination may be an issue, due to the proximity of the degrader, modulator and collimator(s). 

To this, I might add that the construction of the prototype is still awaiting FDA approval, and we have not seen any data on how this machine operates. We are just in the middle of a never ending scandal about a couple of diesel IC4 trains ordered from AnsaldoBreda a decade ago, where the trains still are not functional and with a significant risk that they never will be. Billions of taxpayer money are lost here. Most Danes are therefore allergic to order unproven technology abroad.

Update: Mevion just got their FDA approval.

Another update: it's a "Premarket Notification" and not a "New Device Approval". Read it here. Thanks to Klaus Seiersen for pointing this out.

The recent article in Dagens Medicin does not even mention that cutting 75% of the price leads to a single-gantry facility, which means the patient numbers needs to be adjusted down, perhaps by 2/3rds.

Finally, if you need three treatment rooms, then measured in costs per treatment room, a conventional solution is cheaper than the Mevion solution, according to Schippers.

I am very astonished, it seems that Copenhagen just scored an own goal. However, I fear this may delay the decision process even more. In the end this is about patients, and if the money is there, we should not be satisfied with giving our patients the most inferior kind of proton therapy, and rely on unproven technology.